JPediatr(RioJ).2017;93(1):6---16
www.jped.com.br
REVIEW
ARTICLE
Therapeutic
play
to
prepare
children
for
invasive
procedures:
a
systematic
review
夽
,
夽夽
Rosalia
Daniela
Medeiros
da
Silva
a,∗,
Silvia
Carréra
Austregésilo
a,
Lucas
Ithamar
a,
Luciane
Soares
de
Lima
a,baUniversidadeFederaldePernambuco(UFPE),ProgramadePós-graduac¸ãoemSaúdedaCrianc¸aedoAdolescente,
Recife,PE,Brazil
bUniversidadeFederaldePernambuco(UFPE),ProgramadePós-graduac¸ãoemEnfermagem,Recife,PE,Brazil
Received2May2016;accepted11May2016 Availableonline30July2016
KEYWORDS
Children;
Playandplaythings; Anxiety;
Behavior; Hospitalcare
Abstract
Objective: Toanalyzetheavailableevidenceregardingtheefficacyofusingtherapeuticplay
onbehaviorandanxietyinchildrenundergoinginvasiveprocedures.
Datasource: ThesystematicreviewsearchwasperformedintheMEDLINE,LILACS,CENTRAL
andCINAHLdatabases.Therewasnolimitationontheyearorlanguage.
Synthesisofdata: Theliteraturesearchfound1892articlesandselected22forfullreading.
Eightarticleswereexcluded,astheydidnotaddresstheobjectivesassessedinthisreview.
Twelvestudies,representing14articles,wereincluded.Thestudieswereconductedbetween
1983and2015,fiveinBrazil,oneintheUnitedStates,fiveinChina,oneinLebanon,onein
Taiwan,andoneinIran.Moststudiesshowedthatinterventionwiththerapeuticplaypromotes
reductioninthelevelofanxietyandpromotescollaborativebehaviorandacceptanceofthe
invasiveprocedure.
Conclusions: Evidencerelatedtotheuseoftherapeuticplayonanxietyandbehaviorof
chil-drenundergoinginvasiveproceduresisstillquestionable.Theabsence,inmoststudies,ofthe
creationofarandomsequencetoassignthesubjectstoeitherthecontrolorthe
experimen-talgroup,aswellasallocation concealment,arefactorsthatcontributetothesequestions.
Anotherissuethatcharacterizesanimportantsourceofbiasistheabsenceofblinded
evalua-tors.Itisnecessarytoperformfurtherstudiesthatwilltakeintoaccountgreatermethodological
stringency.
©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Thisisanopen
accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/
4.0/).
夽
Pleasecitethisarticleas:SilvaRD,AustregésiloSC,IthamarL,LimaLS.Therapeuticplaytopreparechildrenforinvasiveprocedures:
asystematicreview.JPediatr(RioJ).2017;93:6---16.
夽夽
StudyconductedatUniversidadeFederaldePernambuco(UFPE),Recife,PE,Brazil.
∗Correspondingauthor.
E-mail:rosaliadaniela@hotmail.com(R.D.Silva).
http://dx.doi.org/10.1016/j.jped.2016.06.005
0021-7557/©2016SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND
Therapeuticplaytopreparechildrenforinvasiveprocedures 7
PALAVRAS-CHAVE
Crianc¸a;
Jogosebrinquedos; Ansiedade;
Comportamento; Assistênciahospitalar
Brinquedoterapêuticonopreparodecrianc¸asparaprocedimentosinvasivos:revisão sistemática
Resumo
Objetivo: Revisar, de forma sistemática, as evidências em relac¸ão a eficácia da utilizac¸ão
do brinquedo terapêutico sobre o comportamento e a ansiedadede crianc¸as submetidas a
procedimentosinvasivos.
Fontesdosdados: AbuscadarevisãosistemáticafoiefetuadanasbasesMedLine,Lilacs,
CEN-TRALeCINAHL.Nãohouvelimitac¸ãoquantoaoanoouidioma.
Síntesedosdados: Nabusca deliteraturaforamencontrados1892artigoseselecionados22
para leituraintegral.Foramexcluídos8artigosquenão respondiamaosobjetivos avaliados
nesta revisão.Foram incluídos12 estudos, correspondentesa 14 artigos. Osestudos foram
conduzidos entre1983e2015, cinconoBrasil, umnos EstadosUnidos, cinconaChina, um
noLíbano,umemTaiwaneumnoIrã.Amaioriadosestudosmostrouqueaintervenc¸ãocom
brinquedoterapêuticopromovereduc¸ãononíveldeansiedadeefavoreceumcomportamento
decolaborac¸ãoeaceitac¸ãodoprocedimentoinvasivo.
Conclusões: Asevidênciasrelacionadasao usodobrinquedoterapêuticosobreaansiedadee
comportamentodecrianc¸assubmetidasaprocedimentosinvasivosaindasãoquestionáveis.A
ausência,namaioriadosestudos,deumagerac¸ãodesequênciaaleatóriaparadirecionamento
dossujeitosparaosgruposcontroleouexperimentaledosigilodealocac¸ãosãofatoresque
contribuemparaestequestionamento.Umaoutra questãoquecaracterizaimportantefonte
deviéséonãocegamentodosavaliadores.Sefaznecessárioarealizac¸ãodenovaspesquisas
quelevememconsiderac¸ãoummaiorrigormetodológico.
©2016SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Este ´eumartigo
OpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.
0/).
Introduction
Thedegree ofthechildren’sunderstandingabout the pro-ceduretowhichtheywillbesubmittedmayberelatedto theperiodofstressandinsecuritythattheywillexperience. Theirbehaviormayvaryaccordingtoage,environment,the presenceofstrangers,andinvasiveproceduresexperienced by thechildren or observedin others. These factors con-tribute to the development of unpleasant reactions such asfear,anxiety,andresistancetotheproceduresthatwill beperformed.Hospitalizationmeansattackingtheirplayful andmagicalrealm,andthereforerequiresthattheassisting professionalunderstandstheirchildhoodworld.1,2
Excessivestressandanxietyexperiencedbychildrencan affecttheirphysical andphysiological health,hindertheir ability todealwithmedicalprocedures,causechangesin theirbehavior,andaffecttheirrecoveryfromillness. There-fore, there is an urgent need for clinical researchers to develop, implement, and evaluate interventionsthat can minimize the children’s anxiety level and improve their abilitytohandlethestress ofhospitalizationand invasive procedures.3
Over the past decades, several studies that addressed children’shealthcarehave discusseddifferentmethodsof educationalinterventionsforchildrenbeforeorduring hos-pitalization,whensurgicalandinvasivemedicalprocedures areperformed.4---9
Theneedtoplayisnoteliminatedwhenchildrenbecome ill or are hospitalized;on the contrary, children who can playmayfeelsaferduringthetransoperativeperiod,even in a strange environment.10 Oneaspect of suchactivities
istherapeuticplay,whichprovidesastructuredplay activ-ity,followstheprinciplesofplaytherapy,andhasspecific objectivestobeachieved.Itsusebringsrelieffromanxiety causedbyatypicalexperiencesforagethattendtoappear asthreatening,requiringaninterventionthatwillhelpthe child/familytocopewhileundergoingahighlycomplex inva-siveprocedure.11
Studies have shown the benefits of therapeutic play inreducinganxiety andpostoperativepaininhospitalized children.12 Clinical trials have shown the positive effects
oftherapeutic play intervention onperioperative anxiety, postoperativepain,andnegativebehaviorinchildren sub-mittedtosurgicalprocedures.7,9
Thus,withtheobjectiveofcontributingtotheknowledge about the use of therapeutic play, which is an important strategytobeusedinchildcare,thisreview aimedto sys-tematically assess the evidence regarding the efficacy of usingtherapeuticplayonthebehaviorandanxietyin chil-drenundergoinginvasiveprocedures.
Method
The protocol of this review is registered at the inter-national database for systematic reviews, PROSPERO, under number CRD42016035878, and can be accessed at (http://www.crd.york.ac.uk/PROSPERO/displayrecord. asp?ID=CRD42016035878).Thisarticlewaswrittenaccording toPRISMArecommendationsforsystematicreviews.13
8 SilvaRDetal.
search in the MEDLINE, LILACS, CENTRAL, and CINAHL databases.
Aspecificstrategycrossingthedescriptorsorkeywords forretrievingsubjectsfromscientificliteraturewascreated foreachsearchportal.
In MEDLINE, through the PubMed search portal, the searchstrategywasperformed usingthesyntax: ((‘‘Child, Preschool’’[Mesh] OR ‘‘Child, Hospitalized’’[Mesh] OR ‘‘Child’’[Mesh]OR‘‘Children’’[Mesh])AND(‘‘Playand Play-things’’[Mesh]OR‘‘PlayTherapy’’[Mesh]OR‘‘Therapeutic Play’’[Mesh])AND(‘‘Nurses’’[Mesh]OR‘‘Speech’’[Mesh]OR ‘‘Pediatric Nurse Practitioners’’[Mesh] OR ‘‘Pain Manage-ment’’[Mesh]OR‘‘ChildBehavior’’[Mesh]OR‘‘Psychology, Child’’[Mesh] OR ‘‘Surgery’’[Mesh] OR ‘‘Pediatric surgery procedure’’[Mesh]OR‘‘PreoperativeCare’’[Mesh])).
In Lilacs, the strategy used was: ‘‘CHILD’’ OR ‘‘PRESCHOOLER’’ AND (play and playthings) OR (Play Therapythrough)OR(Therapeuticplay)AND(perioperative Nursing) OR (Humanizationof assistance) OR Communica-tionOR(PediatricNursing)OR(PainIntervention)OR(Child Behavior) OR (Child Psychology) OR (Pre-Operative Care) OR(ClinicalProcedures)OR(Surgery)OR(PediatricSurgery) OR(PlayTherapy).,however,searchstrategyinLilacs,was performedwithtermsinPortuguese.
In the CENTRAL and CINAHL databases: ((‘‘Child, Preschool’’ OR ‘‘Child, Hospitalized’’ OR ‘‘Child’’ OR ‘‘Children’’) AND(‘‘Play and Playthings’’ OR ‘‘Play Ther-apy’’OR‘‘TherapeuticPlay’’)AND(‘‘Nurses’’OR‘‘Speech’’ OR ‘‘Pediatric Nurse Practitioners’’ OR ‘‘Pain Manage-ment’’ OR ‘‘Child Behavior’’ OR ‘‘Psychology, Child’’ OR ‘‘Surgery’’ OR ‘‘Pediatric surgery procedure’’ OR ‘‘PreoperativeCare’’)).
After the articles were located, the eligibility, selec-tion, and exclusion criteria were applied. The following were considered eligible: original articles (clinical trials andquasi-experimentalstudies)thathadpreschoolersand school-agedchildrenasthestudypopulationandthatused therapeuticplayastheinterventiontopreparechildren sub-mittedtoinvasiveprocedures.Annalsfromcongresseswere excluded, as well as theses, dissertations, letters to the editor,andarticlesnotconsistentwiththestudyquestion. Therewasnolimitationregardingtheyear orlanguageof publication.
Initiallythe article titles were read and,after exclud-ing those that did not meet the eligibility criteria, their abstracts were analyzed according to the same criteria. Thesestepswereperformedindependentlybytwoauthors ofthissystematicreview.Incaseofdisagreementregarding theexclusionoftheabstracts,thearticleswerereadinfull. Afterthearticleswerereadinfull,anewexclusionwas carriedout,accordingtothesamestudyselectioncriteria. Disagreements were resolved by consensus or after con-sultingathird reviewer. Astandard formpreparedbythe authorswasusedfordataextraction.
The decision regarding the risk of bias was performed in two steps. The first was related to the description of whatwasreportedineachstudy,insufficientdetailssothat thedecisionwasmadebasedonthisinformation.The sec-ondpartconsisted ofadecision regardingtherisk ofbias foreachoftheanalyzedparameters,whichwereclassified intothreecategories:lowriskofbias,highriskofbias,and uncertain bias, according to the recommendations of the
tooldevelopedbytheCochraneCollaborationforbiasrisk assessmentinrandomizedclinicaltrials.14,15
Results
A total of1892 articles were found: 1052 in MEDLINE, 95 in CENTRAL, 722 in CINAHL, and 23 in LILACS. Of these, 1861 were excluded for not meeting the eligibility crite-ria and 10 were excluded because they were duplicates. Afterreadingthe21articlesinfull,thefinalsampleofthis reviewcomprised12studies,correspondingto14articles, takingintoaccountthatoneofthestudiesgeneratedthree publications.Fig.1showstheprocessofarticleselection.
Ofthe14articles,tenwererandomizedcontrolled tri-als andfourwere quasi-experimentalstudies. The studies were carriedoutbetween 1983and 2015in the following countries: fivein Brazil, one in the UnitedStates, five in China,oneinLebanon,oneinTaiwan,andoneinIran.The studies were conducted in large and smallhospitals. The participantswereagedbetween3and15years(938 partici-pants).Detailedinformationregardingthearticlesincluded inthisreviewisshowninTable1.
In this review, all studies used therapeutic play to preparechildrenwhowouldbesubmittedtoinvasive proce-dures.Thematerialsandstrategiesusedduringthesessions were varied: representative dolls withsize similarto the child,9,16---19dolls,20---22hospitalobjects,20---25storytelling,role
playing,coloringbookswithallstepsofthetreatment,clay molding,painting,videogamesandcartoonsprojectedon theceilingofthetreatment roomduringtheprocedure,26
videosaboutthesurgerywithpicturesoftheoperatingroom environment, play activities withthe use of toys,games, books,comics,movies,televisionanddrawingmaterials,7,27
anddemonstrationwiththeuseofpuppets.7Onestudyalso
askedthechildrentotaketheirfavoritedoll.26Theduration
ofeachtherapeuticplaysessionrangedfrom15minutesto onehour.
Additionally, some studies also included a visit to the reception, anesthetic induction, operation, and recov-ery rooms, mimicking the entire treatment process,from the child’s admission into the hospital to the operating room.9,16---19 In ten articles, the children were submitted
to elective surgery7,9,16---20,24,25,27 and the other
proce-dures consisted of radiotherapy,26 vaccination,22 blood
collection,21anddentaltreatment.23
In this review, the outcomes of interest were the child’s anxiety and behavior when submitted to an invasive procedure; of the 14 articles found, four ana-lyzed only anxiety,17,19,26,27 while another six analyzed
behavior,4,7,20---22,24andfouranalyzedbothoutcomes.9,16,18,25
Otheranalyzedoutcomesconcernedtheeffectof thera-peuticplaythroughtheanalysisofphysiologicalindicators suchasheartrate,23,26bloodpressureandpulse,7and
sali-varycortisollevel.26Additionally,thelevelofpostoperative
painwasevaluatedinthreearticles,9,18,25andtheparents’
satisfactionandanxietywerealsoverified.9,16,19
Severaltoolswereusedtoanalyzethelevelofanxiety, whichweremostlyscales,includingtheChineseversionof the State Anxiety Scale for Children (CSAS-C),9,16,18,19 the
SpielbergerStateAnxietyScaleforchildren(SSAS-c),17 the
Therapeuticplaytopreparechildrenforinvasiveprocedures 9
14 articles included in the review
Excluded articles (7) -Annals of Congress (1) -Methodological considerations (1) -Outcome assessed in parents (1) -Emotional scale assessment (1) -Note about the research (1) -Child not submitted to invasive procedure (1) -Letter to the Editor (1) 21 abstracts selected for
full text reading
Inclusion
Eligibility
Selection
Identification 1892 articles found
1775 excluded after reading the titles
31 articles 117 articles
10 duplicated articles
86 excluded after reading the abstracts Central
95 results
Cinahl 722 results
Lilacs 23 results
Medline 1052
Figure1 Representativeflowchartoftheselectionstepsofarticlesincludedinthesystematicreview.
(BAI-Y),26theStateAnxietyScaleforChildren(SAS-C),25and
themodifiedYalePreoperativeAnxietyScale(YPAS).27
Thetimingofoutcomeverificationvariedinthe12 stud-ies. Most verified the outcome before and after surgery. Otherstudiesverifieditatadmissionandduringthe preoper-ativeanestheticinjection.Onestudyassessedittwoweeks later.7Othermomentswereduringvenipuncture,whenthe
wound dressings werebeingperformed, during anesthetic induction,attheremovalofpacemakerwires,andat phys-icalexamination,amongothers.
The followingtoolswereusedtoanalyzebehavior:the Cooperation Scale and Manifest Upset Scale,7,23 the
Chil-dren’sEmotionalManifestationScale,9,16,18,25aformcreated
by theresearcher,20,21,24 theWong and BakerScale,20 and
interviewwithaparent/guardian.22
As for the methodological quality of the articles, only one study generated the allocation sequence in the groups in a truly random fashion, by using a soft-ware program Research Randomizer (Urbaniak. G.C., & Plous. S. (2013). Research Randomizer (Version 4.0) from http://www.randomizer.org/) and protected concealment byusingopaqueenvelopes ofthesame sizewithinabox, withparticipantinstructionconductedbytelephone.25Four
articles used a simple randomization method by drawing lots,usingballs:oneidentifiedwiththeexperimentalgroup andtheotherwiththecontrolgroup---oneball wastaken foreach childandwasthenputbackintothebag.9,16,17,19
Theothersthatcarriedoutclinicaltrialsdidnotreportthe methodusedfortherandomization.
There wasnoblindingofthe participantsinanyof the studies,asitwasnotnecessary,consideringthe character-istic of the intervention (therapeutic play). However, the
evaluator was blinded in five studies.7,16,17,23,25 Regarding
sampleloss, onlyone studyindicated that18 andusedthe
appropriate statistical analysis in a clear manner. Simi-larly, only one showedprotocol publicationregarding the research,availableonline.25
Anxiety
Inthisreview,thearticlesthatanalyzedtheeffectivenessof therapeuticplayontheperioperativeanxietylevelof chil-drenundergoinginvasivemedicalproceduresuseddifferent measurementtools.Inthefourarticlesthatproposedto ver-ifytheeffectonlyonanxiety,thisassessmentwasconducted by measuring it before and after surgery.9,16,17,19 Another
studyperformeditatadmissionandduringthepreoperative anestheticinjection.7
Studiesshowthataftertheinterventionwiththeuseof therapeuticplaythechildrenintheexperimentalgrouphad lowerlevelsofanxietywhencomparedtothecontrolgroup (p<0.05).19,26,27Eveninastudyinwhichplayactivitieswere
usedatthemomentpriortothesurgeryinarecreationroom duringashort15-minuteperiod,itfoundthat92%ofchildren intheexperimentalgroupdidnotdisplayanxiety.27
10
Silva
RD
et
al.
Table1 Synthesisofthearticles.
Author(yearof
publication),and
place
Studypopulation
andsamplesize
Studydesign Strategyandmaterialsused,
durationandmomentwhenthe
therapeuticplaysessionwas
carriedout
Assessedoutcomeandevaluation
method
Results
Bruceetal.(1983)
USA
45childrenaged
3---4years,
submittedto
dentalextraction
andrestoration
Experimental •Hospitalobjects.Parentsand
childrenactedaspatientand
professionalandsimulatedthe
procedure
•A20---25minsessionontheday
beforetheprocedure
•Cooperation,negativebehavior
andheartrate
•ManifestUpsetScale
•CooperationScale
Monitoringofheartratefor2min
TheEGrelatedtotheprocedure
wasmorecooperativethanthe
othertwogroups
Lietal.(2007a)a
China
203childrenaged 7---12years undergoing electivesurgery andtheirparents
Experimental •Visitsthereception,anesthetic induction,operationandrecovery rooms
•Representativedollwithasize similartothechild’s
•Representationoftheobtaining ofvitalsigns,anestheticinduction andvenipuncture
•Aone-hoursessionaweek beforetheprocedure
•Childandparents’anxiety, emotionalbehaviorduring anesthesia,postoperativepain andparents’satisfaction
•ChineseversionoftheState AnxietyScaleforChildren (CSAS-C)
•ChineseversionoftheState AnxietyScaleforAdults
•Children’sEmotional ManifestationScale(CEMS) Visualanalogscale(VAS)
Anxietyscoreswerelower, negativebehaviorwasless frequent,andtherewasahigher degreeofsatisfactionamong parentsfromtheEG
Vaezzadehetal. (2011)
Iran
122childrenaged between7and12 yearssubmittedto electivesurgery.
Experimental •Visitsthereception,operation andrecoveryrooms
•Demonstrationinapediatric manikinsimilarinsizetoachild aged6---8years
•Childrenhandledtheequipment andthendemonstratedthe proceduresonthedoll
•Aone-hoursession,oneday beforesurgery
•Anxiety
•SpielbergerStateAnxietyScale forchildren(SSAS-c)
Therewasahigherreductionin meananxietyscoresintheEG preoperatively(31.44±5.87)than intheCG(38.31±7.44)
Yu-Lietal.(2013) Taiwan
19childrenaged 3---15years submittedto radiotherapy
Experimental •Storytelling,role-playinggame, coloringbookswitheverystepof thetreatmentprocess.Child-like doll,claymolding,painting,video gamesandcartoonsprojectedon theceilingofthetreatmentroom duringradiotherapy.One
15---20minsessionaday,every afternoon,fromMondaythrough Friday
•Anxiety
•TheFacesAnxietyScale(FAS)
•BeckYouthAnxietyInventory (BAI-Y)
•Heartrate
•Differencesincortisollevels
Therapeutic
play
to
prepare
children
for
invasive
procedures
11
Table1 (Continued)
Author(yearof
publication),and
place
Studypopulation
andsamplesize
Studydesign Strategyandmaterialsused,
durationandmomentwhenthe
therapeuticplaysessionwas
carriedout
Assessedoutcomeandevaluation
method
Results
Ruschel(1995)
Brazil
60childrenaged
3---10years
submittedto
congenitalheart
defectsurgery
Quasi-experimental
•Materialsrelatedtopreand
postoperativecare.Doll,suture
threads,needles,tweezersand
scissors
•Simulationsurgerywithdoll
•Child’sattitudeinrelationto
severalprocedures
•Form
Therewasstatisticalsignificance
(p<0.05)atthemoments:quiet
wakening,cooperationduring
procedures,acceptingthe
absenceofthemother,andfluid
restriction
Heetal.(2015)
China
95childrenaged
6---14years
submittedto
electivesurgery
Experimental •Videoaboutthesurgerywith
picturesoftheoperatingroom
environment.Demonstrationwith
dollofthepreoperative
procedures.Demonstrationbythe
child
•Manualwithmedicalobjectsand
equipmentusedduringsurgery.
Aone-hoursessionthreetoseven
daysbeforetheprocedure
•Perioperativeanxiety,negative
emotionalexpressionand
post-operativepain
•StateAnxietyScaleforChildren
(SAS-C)
•Children’sEmotional
ManifestationScale(CEMS)
•TheNumericRatingScale(NRS)
Medicalrecord
TheEGshowedlessnegative
emotionalbehaviorbefore
anesthesiainduction,lowlevelsof
anxiety,andlesspostoperative
pain
KicheandAlmeida
(2009) Brazil
34childrenaged
3---10years
submittedto
minorandmedium
surgeries
Quasi-experimental
•Doll,salinesolution,gauze,
adhesivetape,masks,scissors,
dressingforceps,gloves,splints
andotherspecificitemsaccording
tothechild’sdressing
•Twosessions,oneafterthe
dressingandthesecondsessionon
thefollowingday,beforechanging
dressing
•Behaviorsthatshowed
acceptanceandadaptationtothe
procedure
•Form
•WongandBakerscale
Thebehaviorsthatshowlower
acceptanceandadaptationtothe
proceduredecreased,andthose
showinggreateracceptanceand
adaptationincreasedafterthe
therapeuticplaysession
Ribeiroetal.
(2001) Brazil
42childrenaged
3---6years
submittedto
bloodcollection
Quasi-experimental
•Doll,syringe,testtube,cotton,
adhesivetape.Scalpelwithone
catheterandbottlewithredliquid
•Onesessionbeforethe
procedure.
•Behaviorduringbloodcollection
•Form
TheEGshowedareductioninthe
behaviorsof‘‘aggression,verbal
expression,bodymovement,
expressionofemotion,and
dependence’’andshowedan
increaseinthebehaviorsof
12
Silva
RD
et
al.
Table1 (Continued)
Author(yearof
publication),and
place
Studypopulation
andsamplesize
Studydesign Strategyandmaterialsused,
durationandmomentwhenthe
therapeuticplaysessionwas
carriedout
Assessedoutcomeandevaluation
method
Results
Pontesetal.
(2015) Brazil
60childrenaged
3---6years
submittedto
vaccination procedure
Quasi-experimental
•Doll,disposablesyringes,
needles,cottonandstickersfor
venipuncture
•One20-minutesessionbefore
thevaccination
•Child’sreactions
•Observationduringvaccination
•Interviewwithparent/guardian
TheEGhadmorereactionsof
‘‘beingquiet’’and‘‘collaborating
spontaneously’’;behaviorssuchas
‘‘pushing,’’‘‘clingingto
parents,’’‘‘askingtobepicked
up,’’and‘‘stiffness’’wereless
present.
Behaviorsof‘‘crying,’’‘‘clinging
toparents,’’‘‘flushing,’’and
‘‘moving/agitating’’weremore
presentintheCG
Lietal.(2014)
China
108childrenaged
7---12years
admittedto
undergoelective
surgery
Experimental •Visitstotheoperatingroomand
presentationofequipment
•Demonstrationintheoperating
roomwithadollonthefollowing
procedures.Thepost-anesthetic
recoveryperiodisexplained
•Demonstrationbythechildof
theproceduresonthedoll
•A1-hoursession
•Anxiety,emotionalresponses
duringanesthesiainductionand
satisfactionofparents
•StateAnxietyScaleforchildren
andadults
•Children’sEmotional
ManifestationScale
•Questionnaireand
semi-structuredinterview
TheEGshowedalowerlevelof
anxiety,demonstratedfewer
emotionsduringtheanesthetic
induction,andtheparentsofthe
childrenfromthegroupreported
moresatisfactionaftersurgery
Weber(2010)
Brazil
50childrenaged
5---12years
submittedto
surgery
Experimental •Recreationalactivitieswiththe
useofgames,toys,books,comic
books,movies,TVandmaterials
fordrawing
•Onesession15minafter
enteringtheAmbulatorySurgical
Center,lasting15min
•Anxietylevel
•Observationwhenenteringthe
operatingroomand15minafter
enteringtheroom
•ModifiedYalePreoperative
AnxietyScale
92%ofthechildreninEGdidnot
haveanxiety,whileintheCG,84%
werestillanxious
Zahr(1998)
Lebanon
100childrenaged
3---6years
submittedto
electivesurgery
Experimental •Materialsforpainting,dolls,
puzzlesandbicycles
•Demonstrationusingpuppetsof
thesequenceofeventsfrom
admission,surgerytodischarge
•Thechildwasencouragedto
play,handletheequipmentand
re-presenttheplay
•Onesessioncarriedouttheday
beforetheprocedure
•Behavior,bloodpressureand
pulse
•ManifestUpsetScale
•CooperationScale
•Post-HospitalBehavior
Questionnaire(PHBQ)
ChildrenfromtheEGwerecalmer
thanthosefromtheCG
(2.52±1.28vs.3.76±1.16,
Therapeutic
play
to
prepare
children
for
invasive
procedures
13
Table1 (Continued)
Author(yearof
publication),and
place
Studypopulation
andsamplesize
Studydesign Strategyandmaterialsused,
durationandmomentwhenthe
therapeuticplaysessionwas
carriedout
Assessedoutcomeandevaluation
method
Results
LiandLopeza
(2008) China
203childrenaged 7---12years submittedto surgery
Experimental •Visitstothereception, anestheticinduction,surgeryand recoveryrooms
•Demonstrationofprocedureson adollwithsizesimilartothatofa child
•Aone-hoursessioncarriedout oneweekbeforetheprocedure
•Anxietyofthechildrenandtheir parentsandparentalsatisfaction
•ChineseversionoftheState AnxietyScaleforChildren (CSAS-C)
•ChineseversionoftheState AnxietyScaleforAdults
•ThePostoperativeParents’ SatisfactionQuestionnaire (PPSQ)
TheEGshowedstatisticallylower anxietyscoresinthepre-and postoperativeperiods(F[1,201]¼ 5:36,p<0.02)andlessfrequent negativebehaviorthantheCGand theirparentsshowedagreater degreeofsatisfaction
Lietal.a(2007b)
China
203childrenaged 7---12years submittedto electivesurgery
Experimental •Visitstothereception, anestheticinduction,surgeryand recoveryrooms
•Demonstrationofprocedureson adollwithsizesimilartothatofa child
•Child’sanxiety,behaviorand levelofpostoperativepain
•ChineseversionoftheState AnxietyScaleforChildren (CSAS-C)
•Children’sEmotional ManifestationScale(CEMS)
•Visualanalogscale(VAS)
ChildrenfromtheEGandtheir parentsshowedloweranxiety scoresinthepre-and postoperativeperiods
(F[1,201]¼5.36,p<0.02);less frequentnegativebehavior(t [201]¼ 5.4,i<.0001)andtheir parentsshowedagreaterdegree ofsatisfaction
EG,experimentalgroup;CG,controlgroup.
14 SilvaRDetal.
Behavior
All articles assessing behavior showed that children in the experimental group were more collaborative and showedmoreacceptancereactionstotheprocedurewhen compared to the control group. Seven studies express these results with a statistically significant difference (p<0.05).
Onestudyindicatedthatthetherapeuticplay interven-tionsignificantlyreducedthenegativeemotionalbehavior ofchildrenbeforeanestheticinduction.9InthestudybyZahr
in 1998,7 the children in the experimental group showed
fewernegative behaviorswithintwo weeksafter surgery, withthechangeinbehaviorbeingmeasuredbyPost Hospi-talizationBehaviorQuestionnaire(PHBQ).
Thechildren intheexperimentalgroupweremore col-laborative;theyscreamed,demanded, denied,wept,and moved less than those in the control group.21 Regarding
theassessment of negativeemotional behaviorsusingthe Children’s Emotional Manifestation Scale (CEMS), another study found that children in the experimental group had significantly lower mean CEMS scores before anesthetic induction than those in the control group (F=13.452,
p<0.01).25
Children who received the therapeutic play interven-tionexhibitedfeweremotionsattheanestheticinduction, withalargeeffectsizefortheintervention.18Childrenwho
receivedtheinterventionexhibitedsignificantlyless nega-tiveemotional behaviorbeforetheanestheticinduction (t
[201]¼---5.4,p<0.001).9
Discussion
Childrensubmittedtoinvasivemedicalproceduresundergo alltypes of psychological and physical stress, as dotheir families.Veryoften,thehospitalenvironmenttowhichthe childisexposedisquitefrightening,wherethischild’s anx-ietyandbehavioralcycle isaltered.28 Thus,it isessential
tounderstandthebestwaystomitigatethenegative alter-ationsinthesefactors.
This is the first systematic review on therapeutic play interventioninchildrensubmittedtoseveralinvasive pro-cedures,withnotimelimit forthepublicationofstudies, consideringthatapreviouslypublishedreviewonthistopic had a population of children undergoing elective surgery onlyandincludedarticlespublishedbetween1995and2012, inadditiontoalsorestrictingthepublicationlanguage.29
The studiesincluded inthisreview werecarriedoutin developedanddevelopingcountries,largeandsmall hospi-tals,with children’sages withina wide range, submitted to several invasive procedures such as elective surgery, vaccination,blood collection, and dentaltreatment. This demonstratestheuseof therapeuticplayindifferent sce-narios,supportingeffectivecommunicationwiththechild, seekingtoreducetheprobabilityofdevelopingtrauma,as wellaspromotingcollaborativebehaviorbeforeaninvasive procedureisperformed.
Several materials and strategies were used during the therapeutic playsessions. However, ofthe 14 articles,13 usedadoll andhospitalobjects toshow thechildren the proceduretowhichtheywouldbesubmitted.
Theuse ofthesetoolsis inaccordancewiththe state-mentthat,fromthepre-operationalstage,thechildstarts to develop the ability to think about objects and events that are not present in her immediate environment and begins torepresent them throughmental figures, sounds, images,words,orotherforms.Thisnewabilityallowsthem toexceedthelimitsofthe‘‘here andnow’’andbeginto understand that a mental image or ideamay represent a symbolforanobjectoralivedexperience.30
Five articles9,16---19 used in the experimental group, in
additiontotherapeuticplay,visitstothereception,surgery, anesthesiainduction, andrecoveryrooms inorderto pro-mote the child’s familiarization with the environment. In these cases, this may be considered a study limitation, because the association of another therapeutic measure may have overestimated the effect of therapeutic play on the children’s anxiety level and behavior in these studies.
Nostandardization exists in the choice of toolto ana-lyzethechildren’sanxietyandbehavior.Moststudieschose tousevalidatedscales,guaranteeingthattheirapplication allowsthe truemeasurement of whatistobe assessed.31
Theuseofphysiological indicatorssuchasbloodpressure, heartrate,andcortisollevelisveryimportanttoadd evi-denceregardingtheimpactoftherapeuticplayuseonthe child’semotionalstate;however,thesemeasureshavebeen usedinfewstudies.
Moststudieshavefoundpositivechangesinthebehavior ofchildrenwhoparticipatedinthetherapeuticplaysession, as well asreduction in anxiety scores after the interven-tion, whencompared tothe control group.However,few studies analyzed whether this differencewas statistically significant.Somestudiesshowedresultsonlyinabsoluteand relativefrequencies,makingitdifficulttoevaluatewhether the intervention made a difference regarding the child’s anxietyandbehavior.
Oftheninearticlesthatassessedanxiety,three9,18,23did
nothaveenoughinformationonrandomizationand alloca-tionconcealment,whichcomplicatesthebiasriskanalysisin relationtothesepoints,whiletwostudies26,27didso
inad-equately. Whateverthe assessed intervention or outcome was,oneofthefundamentalprinciplesforconducting clin-icaltrials is therandomizationof subjects toprovide the maximumpossiblehomogeneity betweengroupsandallow theinferencethattheassesseddifferencesmaybedueto theintervention.32
Fourarticlesshowedlowriskofbiasregardingthe gener-ationofthesubjects’sequenceandallocation.Inthissense, thelackoftheadequategenerationofsequenceand allo-cationconcealmentcompromisestheevidenceprovidedby thesestudiesforthisoutcome,indicatingacertaindegree ofuncertaintyofthefindings.
Regardingthebehavioroutcome,fivestudies7,20---22,24did
notperformrandomallocationofsubjects,makingit impos-sible for all theparticipants tohave the same chance of beingallocatedinoneofthegroups(controland interven-tion).Also,theydidnotreportonallocationconcealment. Twoarticles18,23 didnothaveenoughinformationregarding
Therapeuticplaytopreparechildrenforinvasiveprocedures 15
thetherapeuticplayonthebehaviorofchildrenundergoing invasiveproceduresisquestionable.
Ineducationalinterventionssuchastherapeuticplay,it is difficult toblind the participants33 becausethe
experi-mentalgroupmembersareawarethatthetherapeuticplay interventionisnotpartoftheusualhospitalcare.Instudies whereagroupissubmittedtoaninterventionandanother to the usual routine care, blinding the researcher or the professionalwhowillperformtheprocedureisnotpossible. The lackof blindingof participantsdoes notrepresentan importantsourceofbias,sinceitisnotexpectedfor chil-drentointentionallychangetheirbehaviorwhentheyknow theyarebeingassessed orbecausetheyparticipated in a certainintervention.
Itispossibletoblindtheevaluator,butthisonlyoccurred intheevaluationaftertheinterventionintwostudiesthat assessedonlybehavior,7,23 onethatassessedonlyanxiety,19
andanotherthatassessedanxietyandbehavior.25Thelack
ofevaluatorblindinginmoststudiesrepresentsariskofhigh bias,whichmakestheevidencequestionable.
Asforincompleteoutcomes,moststudiesshowed insuf-ficientinformationtoassessthisrisk,astheywereunclear whether there was a loss of data, except one18 that
assessed anxiety and behavior, and recorded the loss of fivemembersfromtheintervention groupandfourin the follow-up.However,thereasonwasnotexplainedandthere wasnoinformationregardingwhetheranyadjustmentwas madeinthe analysistoconsidertheselosses.In2015,He etal.25 evaluatedanxiety andbehaviorand reportedthat
nolossesoccurredduringthestudy,whichimplieslowrisk of bias. At this point, the analysis of evidence becomes uncertain.
Possible risks to the validity of intervention studies in children have been discussed in the literature, among which are: insufficient statistical power,34 little concern
forthereliabilityandvalidityofmeasuringtools,35
insuffi-cientverificationofanintervention,36lackofminimization
of attrition bias,37 inability to control observer bias,8
and inability to ensure the integrity and uniformity of treatment.38
Conclusion
Evidencerelatedtotheuseoftherapeuticplayonanxiety andbehaviorofchildrenundergoinginvasiveproceduresis stillquestionable.Theabsence,inmoststudies,ofthe cre-ationofarandomsequencetoassignthesubjectstoeither thecontrolortheexperimentalgroup,aswellasallocation concealment,arefactorsthatcontributetothesequestions. Anotherissuethatcharacterizesanimportantsourceofbias istheabsenceofblindedevaluators.
Therefore,itisnecessarytoperformfurtherstudiesthat will take intoaccount greater methodologicalstringency, especiallyregardingtheallocationofsubjects,useof vali-datedtools,andblindedevaluators,sothattheriskofbias relatedtothesedomainscanbeminimized.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.SoaresVV,VieiraLJ.Percepc¸a˜odecrianc¸ashospitalizadassobre realizac¸a˜odeexames.RevEscEnfermUSP.2004;38:298---306.
2.Melo LR, Petengill AM. Dor na infância: atualizac¸a˜o quanto à avaliac¸a˜o e tratamento. Rev Soc Bras Enferm Ped. 2010;10:97---102.
3.Li WH, Chung OK. Enhancing the efficacy of psychoeduca-tional interventions for pediatric patients in a randomised controlled trial: methodological considerations.J Clin Nurs. 2009;18:3013---21.
4.Ellerton ML,MerriamC.Preparingchildrenand families psy-chologically for day surgery: an evaluation. J Adv Nurs. 1994;19:1057---62.
5.CarpenterKH.Developingapediatricpatient/parenthospital preparationprogram.AORNJ.1998;67:1042---6.
6.BrennanA.Caringforchildrenduringprocedures:areviewof theliterature.PediatrNurs.1994;20:451---8.
7.Zahr LK. Therapeutic play for hospitalized preschoolers in Lebanon.PediatrNurs.1998;24:449---54.
8.O’Conner-VonS.Preparingchildrenforsurgery---anintegrative researchreview.AORNJ.2000;71:334---43.
9.WilliamLiHC,LopezV,LeeTL.Effectsofpreoperative thera-peuticplayonoutcomesofschool-agechildrenundergoingday surgery.ResNursHealth.2007;30:320---32.
10.Maia EB,Ribeiro CA,BorbaRI.Brinquedo terapêutico: bene-fícios vivenciados por enfermeiras na prática assistencial à crianc¸aefamília.RevGauchaEnferm.2008;29:39---46.
11.SteeleS.Conceptofcommunication.In:SteeleS,editor.Child healthandthefamily.NewYork:Massom;1981.p.710---38.
12.ArmstrongTS,AitkenHL. Thedevelopingroleofplay prepa-ration in paediatric anaesthesia. Paediatr Anesth. 2000;10: 1---4.
13.MotherD,LiberatiA,TetzlaffJ,AltmanDG,ThePRISMAGroup.
PreferredReporting Items for SystematicReviews and
Meta-Analyses:thePRISMAstatement[cited19April2016].Available
from:www.prisma-statement.org
14.CarvalhoAP,SilvaV,GrandeAT.Avaliac¸ãodoriscodeviésde ensaiosclínicosrandomizadospelaferramentadacolaborac¸ão Cochrane.DiagnTratamento.2013;18:38---44.
15.HigginsJPT, AltmanDG.Chapter 8:Assessing riskof bias in
includedstudies. In:HigginsJPT,GreenS, editors.Cochrane handbookforsystematicreviewsofinterventions.Version5.1.0
[updated March2011].TheCochraneCollaboration [cited19
Feb 2016].Available from:http://hiv.cochrane.org/sites/hiv.
cochrane.org/files/uploads/Ch08Bias.pdf
16.LiHC,LopezV,LeeTL.Psychoeducationalpreparationof chil-dren for surgery: the importance of parental involvement. PatientEduCouns.2007;65:34---41.
17.VaezzadehN,DoukiZE,HadipourA,OsiaS,Shahmohammadi S,SadeghiR.Theeffectofperformingpreoperative prepara-tionprogramonschoolagechildren’sanxiety.IranJPediatr. 2011;21:461---6.
18.LiWH, ChanSS,WongEM, KwokMC,LeeIT.Effectof thera-peuticplayonpre-andpost-operativeanxietyandemotional responsesinHongKong Chinese children:a randomised con-trolledtrial.HongKongMedJ.2014;20:36---9.
19.Li HC, Lopez V. Effectivenessand appropriatenessof thera-peuticplay intervention inpreparing children for surgery: a randomizedcontrolledtrialstudy.JSPN.2008;13:63---73.
20.Kiche MT, Almeida FA. Brinquedo terapêutico: estratégia de alíviodadoretensãoduranteocurativocirúrgicoemcrianc¸as. ActaPaulEnferm.2009;22:125---30.
16 SilvaRDetal.
22.Pontes JE, Tabet E, Folkmann MA, Cunha ML, Almeida FA. Brinquedo terapêutico: preparando a crianc¸a paraa vacina. Einstein.2015;13:238---42.
23.Schwartz BH,AlbinoJE, TedescoLA. Effectsofpsychological preparationonchildrenhospitalizedfor dentaloperations. J Pediatr.1983;102:634---8.
24.RushelPP,CidadeDP,DaudtNS,RossiRI.É válido psicoprofi-laxiaparacirurgiacardíacaemcrianc¸as.ArqBrasdeCardiol. 1995;65:317---20.
25.HeHG,ZhuL,ChanSW,LiamJL,LiHC,KoSS,etal.Therapeutic playinterventiononchildren’sperioperativeanxiety,negative emotionalmanifestationandpostoperativepain:arandomized controlledtrial.JAdvNurs.2015;71:1032---43.
26.TsaiYL,TsaiSC,YenSH,HuangKL,MuPF,LiouHC,etal.Efficacy oftherapeutic playfor pediatricbraintumor patientsduring externalbeamradiotherapy.ChildsNervSyst.2013;29:1123---9.
27.WeberFS.Theinfluenceofplayfulactivitiesonchildren’s anx-ietyduringthepreoperativeperiodattheoutpatientsurgical center.JPediatr(RioJ).2010;86:209---14.
28.LagoPM,PivaJP,GarciaPC,SfoggiaA,KnightG, Ramelet A-S, etal. Analgesia esedac¸ãoem situac¸ões deemergência e unidadesdetratamentointensivopediátrico.Jpediatr(RioJ). 2003;79:S223---30.
29.He HG, Zhu L, Chan SW, Klainin-Yobas P, Wang W. Thera-peutic play intervention in reducing perioperative anxiety,
negativebehaviors,andpostoperativepaininchildren under-goingelectivesurgery:asystematicreview.PainManagNurs. 2015;16:425---39.
30.BeeH,BoydD.Acrianc¸aemdesenvolvimento.Artmed:Porto Alegre;2011.
31.Bellucci Ju´nior JA, Matsuda LM. Construc¸a˜o e validac¸a˜o de instrumentoparaavaliac¸a˜odoacolhimentocomclassificac¸a˜o derisco.RevBrasEnferm.2012;65:751---7.
32.PolitDF,BeckCT.Fundamentosdepesquisaemenfermagem: avaliac¸ãodeevidênciasparaaspráticasdaenfermagem.7ed. PortoAlegre:Artmed;2011.
33.HulleySB,CummingsSR,BrownerWS,GradyDG,NewmanTB. Delineandoapesquisaclínica:umaabordagemepidemiológica. 3ed.PortoAlegre:Artmed;2008.
34.BeckCT. Achieving statisticalpowerthrough researchdesign sensitivity.JAdvNurs.1994;20:912---6.
35.Selby-HarringtonML,MehtaSM,JutsumV,Riportella-MullerR, Quade D. Reporting of instrument validity and reliability in selectedclinicalnursingjournals.JProfNurs.1989;10:47---56.
36.ShuldhamC.Pre-operativeeducation---areviewoftheresearch design.IntJNursStud.1999;36:179---87.
37.FoggL,GrossD.Threatstovalidityinrandomizedclinicaltrials. ResNursHealth.2000;23:79---87.
