An Evaluation of the Effectiveness of Psychological Preparation of Children for Minor Surgery by Puppet Play and Brief Mother Counseling

group. Various measures including the Rutter scales for teachers and parents [10, 11] and the Preschool Behavior Questionnaire [12] were used to assess the children’s behavior before and after the operation. The subcategories assessed by the Rutter questionnaire apart from the total score are conduct and emotional disorders while the Preschool Behavior Questionnaire has the following subcategories: total score, aggressive behavior, anxious behavior and behaviors related to hyperactivity and low concentration skills. In both scales and subscales, a reduction in mean scores denotes an improvement in the behavior of the child. The intervention consisted of two parts: the therapeutic puppet play session for children and the brief counseling session for their mothers. The psychological preparation was carried out the day before surgery, following the baseline assessment. A psychologist who was trained in the puppet play technique administered the preparation program to children undergoing surgery. A manual for the implementation of the psychological preparation program for the mother and child was developed with specific guidelines on the application of the program. The psychologist prepared the child with the semistructured puppet play. The play has been described in detail in a manual developed by researchers after consultation with puppet therapy specialists who worked in hospitals in Scotland (Scottish Mask and Puppet Center), and they were trained by applying the preparation program. During the play, the child takes the role of the doctor while the researcher takes the role of the child-patient, guiding the play according to the structured scenario. Through this play, children are informed in detail regarding hospital stay as well as medical procedures (anesthesia induction and recovery). Furthermore, children are encouraged to express their feelings, fantasies and questions concerning any part of the hospital stay and surgery. The children and their mothers of the control group were admitted to the hospital following the standard admittance procedures that do not include any structured preparation program. In order to assess the effectiveness of the preparation program we had to examine the differences in the mental status of children between experimental (intervention) and control groups. First, we used the independent-sample t test for both age groups in order to detect any significant differences in the behavior of children at baseline. The total scores as well as the subscales of the Behar and Rutter scales showed no significant difference at baseline between intervention and control groups [Behar: t = –0.032, d.f. = 60, not significant; Rutter: t = 0.784, d.f. = 60, not significant]. After, a 2 ! 2 mixed repeated-measures ANOVA with 1 within-subject factor (subscales of the Behar and subscales of the Rutter scale, before and 10 days after surgery) and 1 between-subjects factor (intervention group and control group) was used to examine the effect of within-subject factor and between-subjects factor. A simple main effect analysis was used in order to examine the results of the pairwise comparisons for the simple main effects. Puppet play has been used extensively as a method to prepare children for surgery in hospitals. However, its effectiveness has not been proven experimentally . Concerns have been expressed about children’s reactions to hospitalization and surgical procedures as early as in the 1960s [1, 2] . Children may become particularly distressed during medical procedures while some may even develop psychopathological reactions after surgery, including depression or behavioral, sleep and eating disorders [3–6] . As response to these findings, various psychological preparation programs have been designed and implemented in order to prevent such adverse psychological reactions in children undergoing hospitalization and surgery. Although the puppet play technique has been widely used in pediatric hospitals, it has not been adequately researched for its effectiveness. Cassell and Paul [7] reported that children when prepared with puppet play for cardiac catheterization were less distressed and more cooperative during the medical procedures, though the value of these findings is lacking significance due to the small sample size. Moreover, Linn et al. [8] and Abbott [9] presented the clinical use of puppet play by case studies such as bone marrow transplantation and cardiac surgery, and they have given detailed examples of the method and its effectiveness in the psychological preparation of children. The authors concluded that puppet play can help children cope successfully with medical procedures by education and modeling. The primary goal of the present study was to develop a structured preparation program using puppet play for children who underwent elective surgery as well as their mothers and examine whether this intervention had a positive effect on the child’s preand postoperative distress and behavior. Our sample consisted of 91 children, from 4 to 10 years old, and their mothers; the children were admitted for elective ear, nose and throat surgery at the Aghia Sophia Children’s Hospital, Athens, Greece. The sample was divided into two age groups: ages 4–6 years, preschool age, and ages 7–10 years, school age. All subjects were randomly assigned to either the intervention or control Received: October 10, 2005 Accepted after revision: May 26, 2008 Published online: November 18, 2008