0022-5347 /79/1221-0068$02.00/0 Vol. 122, July
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
BEHAVIOR OF CHILDREN UNDERGOING HYPOSPADIAS REPAIR ADLYNN G. LEPORE
AND
RICHARD W. KESLER
From the Department of Pediatrics and the Hospital Education Program, University of Virginia Medical Center, Charlottesville, Virginia
ABSTRACT
We performed a prospective study on 10 boys between 2 and 6 years old undergoing repair for hypospadias. Clinical observation in the hospital ward rooms and play environment demonstrated a distinctive postoperative course of withdrawal and aggressive behavior with resultant increased parental anxiety, which results in strained staff-family relations. We speculate that this distinctive behavior may be owing to an interaction among parental attitudes, the pain and immobilization from operation and the level of the child's sexual development. Intervention was designed to give the boys behavioral outlets and to involve their family in preoperative and postoperative education. interaction by crying in response to anyone's approach. This scope of behavior is consistent with preoperative patients in general. It was during the postoperative period that behavioral similarities in children with hypospadias emerged. This pattern began with a lack of positive interactions with peers and adults, and lack of spontaneity in initiation of play. Interaction gradually increased in the form of rough manipulation of play materials and aggressive demanding behavior with parents and staff. The 3 boys described herein are representative of the entire group studied and illustrate this behavior.
Hypospadias repair is a delicate surgical procedure occurring at a critical period in a boy's psychosexual development and resulting in a particularly painful and physically immobilizing recovery. Nurses and school teachers involved in the children's preoperative teaching program at the University of Virginia Medical Center frequently have commented upon the especially difficult postoperative behavior of this group of surgical patients as compared to children undergoing other types of operation. Because of these anecdotal comments we undertook a prospective study of these children to describe this behavior pattern and to develop techniques of intervention that may make the recovery period a more pleasant experience for the children, parents and hospital staff. Urologic surgeons will find the information useful in preoperative counseling of parents of boys undergoing hypospadias repair. The techniques of intervention may be used by parents as well as the nursing staff in hospitals in which no preschool teachers are available.
CASE REPORTS
OBSERVATION
During a 22-month period 10 boys between 2 and 6 years old were observed. Three were hospitalized more than once during this observation time. Subjects differed in the position of hypospadias, degree of severity of chordee and number of surgical procedures needed for a successful correction. There were family differences in socioeconomic level, family structure and ordinal position of the subject. There were wide differences among the parents in their degree of understanding of their child's defect and prognosis for surgical repair. Variation also existed in attitudes towards the penile anomaly and the time spent in preparing the child for operation. Observation was conducted informally by one of us (A. G. L.) in the preschool/playroom on the pediatric unit and at the child's bedside. Each child was observed approximately 3 hours daily. The child's interactions were noted during group experiences and individual activities. The following interactions received particular attention: the child's behavior towards materials, his parents and the staff; the parents' comments throughout hospitalization and comments by the staff related to the child and/or his parents. Preoperatively, the affects of the children varied. Several were curious about the new environment, appearing confident and secure in their movement about the ward and in their encounters with the staff. These children all had their parents in tow. Several others were shy and held on tightly to their parents' hands. A few more unfortunate children, whose parents left shortly after admission to the hospital, were noticeably frightened by the situation and actively avoided Accepted for publication September 8, 1978.
68
Case 1. S. S., a 2-year-old white boy, is an only child who lives with his mother and grandparents. Preoperatively, he was described by the staff as an active, age-appropriate child who was shy with strangers but warmed up quickly and played with persons who were friendly toward him. Postoperatively, the boy presented with an important behavior problem. For several days he would not communicate except to cry when the staff and parents approached him. He would not play with any toys that were brought to him. His mother was quiet and allowed the grandmother to repeat that the boy was in so much pain that he should not be bothered but just petted and comforted. The patient became more difficult to care for as his crying and kicking increased during treatments of any kind. When he was brought to the playroom in a stroller he would sit but would not play. The boy finally became interested in water play and played for short periods. Case 2. J. C., a 4-year-old white boy, is quiet, polite and lives with his parents. He spent the afternoon preoperatively in the playroom where he quickly adjusted to the routine. He followed directions well, verbally responding to questions about activities and was generally happy in his work. Although the boy said, when given crayons, that he could not draw he covered the page with shapes and lines and talked fluently about each. Postoperatively, the child maintained his politeness with the teachers but would only respond with a nod or a verbal no when asked if he wanted something. On 1 occasion, after saying no, it was noted that he was watching the others paint. When the teacher asked again if the boy wanted to paint he said yes and did so in a confined area in the middle of the page. For 4 days he continued to do little without encouragement and rarely spoke spontaneously. Also, on the ward the boy was quiet and uninterested in play but when treated by nurses or his mother he expressed his feeling loudly and voiced his demands. This behavior led the nurses to complain about him and caused his mother great anxiety. Because of her concern over the boy's changed affect the
BEHAVIOR OF CHILDREN UNDERGOING HYPOSPADIAS REPAIR
mother talked often of her determination to correct his newly acquired demanding ways by confronting him with strict discipline immediately after their return home. Case 3. P. R., a 5-year-old black boy, was in the hospital a full day before the operation. It was noted that he would occasionally grab toys from other children and would yell when one was taken from him. The child initiated play, cooperated in activities with peers and was able to construct and use a large building. His receptive and expressive language was age-appropriate. Postoperatively, the boy was initially quiet in the playroom. He asked for nothing and responded with only occasional nods to play suggestions. He manipulated blocks with little purpose, caused his toy cars to have multiple collisions and squirted the other children with syringes filled with water. The child's quietness was only interrupted by loud bossy remarks directed at another child or the teacher. This noisy, demanding behavior became more frequent during the next few days, with the most consistently abusive remarks made toward his mother. His behavior on the ward was difficult for his mother to tolerate. On several occasions she left his room and was found by the staff crying in the hall. The staff was perturbed by the mother's unwillingness to set limits on the boy's language and behavior, and they were frustrated by the physical battles he waged against them during treatment.
69
child was included in part of this conversation. Emphasis was placed on letting the child know the teacher thought it was all right for him to be angry. RESULTS
Several trends were apparent as the observations came to an end. The initial family interview was helpful for 3 reasons. Primarily, it prepared the family for more than the physical changes with which they would be confronted. By doing this the parents were not shocked by postoperative demands and trying behaviors of the child. Having been prepared, the parents were able to be slightly more objective and less concerned that the child's personality was forever changed. Frequently, this helped them maintain the strength to set limits and demand certain responses. Secondarily, the parents realized the supportive purpose of the preschool/play staff. They were able to go to them for support, escape and suggestions throughout the child's hospitalization. It was also possible to prepare them for the adjustment period that continues even after returning home. Finally, with respect to the child, this preoperative meeting served as a time for him to become familiar with the preschool/playroom and the teachers. Teachers used the time to observe and interact with the child, acquiring a knowledge of his usual behavior. The staff was encouraged by the realization and understanding that the child's behavior was not their fault and not INTERVENTION directed at them. This perspective helped them support the Intervention was a gradual process. Initial efforts were parents in setting limits and in teaching the parents to directed toward providing a comfortable, non-threatening, understand the adaptive nature of their child's behavior. self-directed and self-expressive environment in which the J.C. (case 2) was hospitalized 3 times in 6 months, twice for child could spend most of his free time. Allowing the children repair and once for a non-operative procedure. We worked to relax in this way, watch the other children and make their closely with this child and his parents from the time of his own decisions about participation had little positive effect first admission to the hospital. At each hospitalization he except to build some trust in the relationship. Although the appeared quieter than the previous time. Postoperatively, importance of trust cannot be disputed the negative aspects of however, after the second major procedure, he warmed up and their behavior, lack of involvement, outweighed the positive. became spontaneous in a fewer number of days. We attribute Having noted previously the aggressive behavior and the this, at least in part, to his familiarity with the preschool aggressive use of toys, we began to encourage physical expres- program and the medical staff, and to his parents' increased sion assuming it provided a needed outlet. Toys, such as cars, ability to support him. During the last 8 months of this study, as more time was blocks, hammers, workbenches, paint supplies, homemade playdoh, medical supplies, dolls and water play equipment, spent actively eliciting behavior from these boys, it was noted were selected. With the more passive boys the teacher solicited that verbalizations and spontaneous interaction increased active expression by sitting with them, playing with the toys, during a fewer number of days than was noted in boys talking to them about the playroom and asking them about hospitalized before initiation of this more aggressive form of what they played with at home. With those boys who were play. naturally more aggressive and who spontaneously remarked DISCUSSION angrily to the other children and teachers early in the first postoperative play session, we provided an atmosphere in These 10 boys undergoing hypospadias repair demonstrated which aggressive use of materials was permissible and encour- a pattern of behavior characterized by anger, aggression and aged. negative interactions. This pattern is sufficiently distinct from Typically, after receiving this much attention and time to that of other surgical patients that nurses and teachers observe all of what was happening in the playroom, the child routinely expected and commented upon it before we made would either start to play with what was before him or point these prospective observations. The answer to why this group to something else. At this time we told him that he needed to of patients should respond with this pattern rather than with use words to ask for things. Whether the child interacted the more typical reactions to hospitalizations, such as clinging passively or actively, we attempted to help him realize and behavior, long-term withdrawal or regression, may lie in the understand his behavior. This was done by saying such things timing or type of surgical procedure and resulting discomfort, as: "You are watching the other children paint, would you like some common experience of these children preoperatively or to paint?" or "This is the children's playroom. Here you may an interaction of both. choose fun things to do. We don't know what you like; you can Unfortunately, the most advantageous time to initiate surghelp me by telling me what you like, then I'll help you to get ical repair in a child with hypospadias is when he is approxiit so that you can play." or "You are hitting that playdoh very mately 3 years old. Before that time the penis may be too hard, are you angry?". small, while later the necessity of multiple procedures may Another important area of intervention dealt with the interrupt school. Holt has identified these boys as a special parents and the preoperative period. As often as possible we risk, since the operation is done during the phallic stage of met with the parents and the child the day before operation. psychosocial development. 1 Developmentally, the child at this While the child played we discussed with the parents the stage is unable to distinguish whether his pain is the result of preparation for hospitalization and the operations the child the corrective operation or induced as punishment. 2 Postoperhad received, the operation itself and some of the behaviors atively, the child is confronted by pain lasting virtually the the child might exhibit postoperatively. When possible the entire hospitalization, by the penis wrapped in gauze, sticking
70
LEPORE AND KESLER
straight up with a catheter coming from it and by a long period of confinement to bed or a wheel chair. It is not surprising that anger, first appearing as withdrawal or passivity and later as aggressive and demanding behavior, appears to be the major response to this attack on his physical integrity. In the preoperative years the hypospadias defects create anxieties in the parents and children, which affect the child's behavior. 3 The children are receiving directly or indirectly signals from their parents that they are indeed somewhat different. These of course will vary depending on the parental attitude toward modesty and teaching about sexual development. For the child brought up by parents noticeably anxious about the social and functional aspects of the penis and who has been discouraged from inquisitive expression about the genitals an operation may pose an even greater threat. Finally, parental attitudes toward this type of operation seem to be different from those toward other types of surgical procedures. The operation itself is not particularly dangerous or of sudden necessity and emotional emphasis by the parents is directed toward success of the repair rather than the child's ability to withstand the surgical procedure. For the parents
the postoperative course is the most anxiety-provoking time because many days must pass before the degree of success is certain. The "special risk" to these children may be compounded by parental anxiety. In summary, we have described a unique pattern of anger and aggression by boys undergoing hypospadias repair. In the process of observing this behavior, techniques of intervention have been developed which may help the surgeon, nursing staff, hospital-based teachers and parents in understanding and coping with the behavior of these children. Exact answers as to the cause of this behavior will depend upon in-depth studies of the children and their families. REFERENCES
1. Holt, J. L.: A long-term study of a child treated for hypospadias. Nurses Clin. N. Amer., 4: 27, 1969. 2. Freud, A.: The role of bodily illness in the mental life of children. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International Universities Press, Inc., vol. 7, p. 69, 1951. 3. Robertson, M. and Walker, D.: Psychological factors in hypospadias repair. J. Urol., 113: 698, 1975.
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright © 1979 by The Williams & Wilkins Co.
BEHAVIOR OF CHILDREN UNDERGOING HYPOSPADIAS REPAIR ADLYNN G. LEPORE
AND
RICHARD W. KESLER
From the Department of Pediatrics and the Hospital Education Program, University of Virginia Medical Center, Charlottesville, Virginia
ABSTRACT
We performed a prospective study on 10 boys between 2 and 6 years old undergoing repair for hypospadias. Clinical observation in the hospital ward rooms and play environment demonstrated a distinctive postoperative course of withdrawal and aggressive behavior with resultant increased parental anxiety, which results in strained staff-family relations. We speculate that this distinctive behavior may be owing to an interaction among parental attitudes, the pain and immobilization from operation and the level of the child's sexual development. Intervention was designed to give the boys behavioral outlets and to involve their family in preoperative and postoperative education. interaction by crying in response to anyone's approach. This scope of behavior is consistent with preoperative patients in general. It was during the postoperative period that behavioral similarities in children with hypospadias emerged. This pattern began with a lack of positive interactions with peers and adults, and lack of spontaneity in initiation of play. Interaction gradually increased in the form of rough manipulation of play materials and aggressive demanding behavior with parents and staff. The 3 boys described herein are representative of the entire group studied and illustrate this behavior.
Hypospadias repair is a delicate surgical procedure occurring at a critical period in a boy's psychosexual development and resulting in a particularly painful and physically immobilizing recovery. Nurses and school teachers involved in the children's preoperative teaching program at the University of Virginia Medical Center frequently have commented upon the especially difficult postoperative behavior of this group of surgical patients as compared to children undergoing other types of operation. Because of these anecdotal comments we undertook a prospective study of these children to describe this behavior pattern and to develop techniques of intervention that may make the recovery period a more pleasant experience for the children, parents and hospital staff. Urologic surgeons will find the information useful in preoperative counseling of parents of boys undergoing hypospadias repair. The techniques of intervention may be used by parents as well as the nursing staff in hospitals in which no preschool teachers are available.
CASE REPORTS
OBSERVATION
During a 22-month period 10 boys between 2 and 6 years old were observed. Three were hospitalized more than once during this observation time. Subjects differed in the position of hypospadias, degree of severity of chordee and number of surgical procedures needed for a successful correction. There were family differences in socioeconomic level, family structure and ordinal position of the subject. There were wide differences among the parents in their degree of understanding of their child's defect and prognosis for surgical repair. Variation also existed in attitudes towards the penile anomaly and the time spent in preparing the child for operation. Observation was conducted informally by one of us (A. G. L.) in the preschool/playroom on the pediatric unit and at the child's bedside. Each child was observed approximately 3 hours daily. The child's interactions were noted during group experiences and individual activities. The following interactions received particular attention: the child's behavior towards materials, his parents and the staff; the parents' comments throughout hospitalization and comments by the staff related to the child and/or his parents. Preoperatively, the affects of the children varied. Several were curious about the new environment, appearing confident and secure in their movement about the ward and in their encounters with the staff. These children all had their parents in tow. Several others were shy and held on tightly to their parents' hands. A few more unfortunate children, whose parents left shortly after admission to the hospital, were noticeably frightened by the situation and actively avoided Accepted for publication September 8, 1978.
68
Case 1. S. S., a 2-year-old white boy, is an only child who lives with his mother and grandparents. Preoperatively, he was described by the staff as an active, age-appropriate child who was shy with strangers but warmed up quickly and played with persons who were friendly toward him. Postoperatively, the boy presented with an important behavior problem. For several days he would not communicate except to cry when the staff and parents approached him. He would not play with any toys that were brought to him. His mother was quiet and allowed the grandmother to repeat that the boy was in so much pain that he should not be bothered but just petted and comforted. The patient became more difficult to care for as his crying and kicking increased during treatments of any kind. When he was brought to the playroom in a stroller he would sit but would not play. The boy finally became interested in water play and played for short periods. Case 2. J. C., a 4-year-old white boy, is quiet, polite and lives with his parents. He spent the afternoon preoperatively in the playroom where he quickly adjusted to the routine. He followed directions well, verbally responding to questions about activities and was generally happy in his work. Although the boy said, when given crayons, that he could not draw he covered the page with shapes and lines and talked fluently about each. Postoperatively, the child maintained his politeness with the teachers but would only respond with a nod or a verbal no when asked if he wanted something. On 1 occasion, after saying no, it was noted that he was watching the others paint. When the teacher asked again if the boy wanted to paint he said yes and did so in a confined area in the middle of the page. For 4 days he continued to do little without encouragement and rarely spoke spontaneously. Also, on the ward the boy was quiet and uninterested in play but when treated by nurses or his mother he expressed his feeling loudly and voiced his demands. This behavior led the nurses to complain about him and caused his mother great anxiety. Because of her concern over the boy's changed affect the
BEHAVIOR OF CHILDREN UNDERGOING HYPOSPADIAS REPAIR
mother talked often of her determination to correct his newly acquired demanding ways by confronting him with strict discipline immediately after their return home. Case 3. P. R., a 5-year-old black boy, was in the hospital a full day before the operation. It was noted that he would occasionally grab toys from other children and would yell when one was taken from him. The child initiated play, cooperated in activities with peers and was able to construct and use a large building. His receptive and expressive language was age-appropriate. Postoperatively, the boy was initially quiet in the playroom. He asked for nothing and responded with only occasional nods to play suggestions. He manipulated blocks with little purpose, caused his toy cars to have multiple collisions and squirted the other children with syringes filled with water. The child's quietness was only interrupted by loud bossy remarks directed at another child or the teacher. This noisy, demanding behavior became more frequent during the next few days, with the most consistently abusive remarks made toward his mother. His behavior on the ward was difficult for his mother to tolerate. On several occasions she left his room and was found by the staff crying in the hall. The staff was perturbed by the mother's unwillingness to set limits on the boy's language and behavior, and they were frustrated by the physical battles he waged against them during treatment.
69
child was included in part of this conversation. Emphasis was placed on letting the child know the teacher thought it was all right for him to be angry. RESULTS
Several trends were apparent as the observations came to an end. The initial family interview was helpful for 3 reasons. Primarily, it prepared the family for more than the physical changes with which they would be confronted. By doing this the parents were not shocked by postoperative demands and trying behaviors of the child. Having been prepared, the parents were able to be slightly more objective and less concerned that the child's personality was forever changed. Frequently, this helped them maintain the strength to set limits and demand certain responses. Secondarily, the parents realized the supportive purpose of the preschool/play staff. They were able to go to them for support, escape and suggestions throughout the child's hospitalization. It was also possible to prepare them for the adjustment period that continues even after returning home. Finally, with respect to the child, this preoperative meeting served as a time for him to become familiar with the preschool/playroom and the teachers. Teachers used the time to observe and interact with the child, acquiring a knowledge of his usual behavior. The staff was encouraged by the realization and understanding that the child's behavior was not their fault and not INTERVENTION directed at them. This perspective helped them support the Intervention was a gradual process. Initial efforts were parents in setting limits and in teaching the parents to directed toward providing a comfortable, non-threatening, understand the adaptive nature of their child's behavior. self-directed and self-expressive environment in which the J.C. (case 2) was hospitalized 3 times in 6 months, twice for child could spend most of his free time. Allowing the children repair and once for a non-operative procedure. We worked to relax in this way, watch the other children and make their closely with this child and his parents from the time of his own decisions about participation had little positive effect first admission to the hospital. At each hospitalization he except to build some trust in the relationship. Although the appeared quieter than the previous time. Postoperatively, importance of trust cannot be disputed the negative aspects of however, after the second major procedure, he warmed up and their behavior, lack of involvement, outweighed the positive. became spontaneous in a fewer number of days. We attribute Having noted previously the aggressive behavior and the this, at least in part, to his familiarity with the preschool aggressive use of toys, we began to encourage physical expres- program and the medical staff, and to his parents' increased sion assuming it provided a needed outlet. Toys, such as cars, ability to support him. During the last 8 months of this study, as more time was blocks, hammers, workbenches, paint supplies, homemade playdoh, medical supplies, dolls and water play equipment, spent actively eliciting behavior from these boys, it was noted were selected. With the more passive boys the teacher solicited that verbalizations and spontaneous interaction increased active expression by sitting with them, playing with the toys, during a fewer number of days than was noted in boys talking to them about the playroom and asking them about hospitalized before initiation of this more aggressive form of what they played with at home. With those boys who were play. naturally more aggressive and who spontaneously remarked DISCUSSION angrily to the other children and teachers early in the first postoperative play session, we provided an atmosphere in These 10 boys undergoing hypospadias repair demonstrated which aggressive use of materials was permissible and encour- a pattern of behavior characterized by anger, aggression and aged. negative interactions. This pattern is sufficiently distinct from Typically, after receiving this much attention and time to that of other surgical patients that nurses and teachers observe all of what was happening in the playroom, the child routinely expected and commented upon it before we made would either start to play with what was before him or point these prospective observations. The answer to why this group to something else. At this time we told him that he needed to of patients should respond with this pattern rather than with use words to ask for things. Whether the child interacted the more typical reactions to hospitalizations, such as clinging passively or actively, we attempted to help him realize and behavior, long-term withdrawal or regression, may lie in the understand his behavior. This was done by saying such things timing or type of surgical procedure and resulting discomfort, as: "You are watching the other children paint, would you like some common experience of these children preoperatively or to paint?" or "This is the children's playroom. Here you may an interaction of both. choose fun things to do. We don't know what you like; you can Unfortunately, the most advantageous time to initiate surghelp me by telling me what you like, then I'll help you to get ical repair in a child with hypospadias is when he is approxiit so that you can play." or "You are hitting that playdoh very mately 3 years old. Before that time the penis may be too hard, are you angry?". small, while later the necessity of multiple procedures may Another important area of intervention dealt with the interrupt school. Holt has identified these boys as a special parents and the preoperative period. As often as possible we risk, since the operation is done during the phallic stage of met with the parents and the child the day before operation. psychosocial development. 1 Developmentally, the child at this While the child played we discussed with the parents the stage is unable to distinguish whether his pain is the result of preparation for hospitalization and the operations the child the corrective operation or induced as punishment. 2 Postoperhad received, the operation itself and some of the behaviors atively, the child is confronted by pain lasting virtually the the child might exhibit postoperatively. When possible the entire hospitalization, by the penis wrapped in gauze, sticking
70
LEPORE AND KESLER
straight up with a catheter coming from it and by a long period of confinement to bed or a wheel chair. It is not surprising that anger, first appearing as withdrawal or passivity and later as aggressive and demanding behavior, appears to be the major response to this attack on his physical integrity. In the preoperative years the hypospadias defects create anxieties in the parents and children, which affect the child's behavior. 3 The children are receiving directly or indirectly signals from their parents that they are indeed somewhat different. These of course will vary depending on the parental attitude toward modesty and teaching about sexual development. For the child brought up by parents noticeably anxious about the social and functional aspects of the penis and who has been discouraged from inquisitive expression about the genitals an operation may pose an even greater threat. Finally, parental attitudes toward this type of operation seem to be different from those toward other types of surgical procedures. The operation itself is not particularly dangerous or of sudden necessity and emotional emphasis by the parents is directed toward success of the repair rather than the child's ability to withstand the surgical procedure. For the parents
the postoperative course is the most anxiety-provoking time because many days must pass before the degree of success is certain. The "special risk" to these children may be compounded by parental anxiety. In summary, we have described a unique pattern of anger and aggression by boys undergoing hypospadias repair. In the process of observing this behavior, techniques of intervention have been developed which may help the surgeon, nursing staff, hospital-based teachers and parents in understanding and coping with the behavior of these children. Exact answers as to the cause of this behavior will depend upon in-depth studies of the children and their families. REFERENCES
1. Holt, J. L.: A long-term study of a child treated for hypospadias. Nurses Clin. N. Amer., 4: 27, 1969. 2. Freud, A.: The role of bodily illness in the mental life of children. In: The Psychoanalytic Study of the Child. Edited by R. S. Eissler, A. Freud, H. Hartmann and E. Kris. New York: International Universities Press, Inc., vol. 7, p. 69, 1951. 3. Robertson, M. and Walker, D.: Psychological factors in hypospadias repair. J. Urol., 113: 698, 1975.
