Medical distress is a common problem among youngsters that has been associated with behavior management and adherence problems. In the pediat-ric patient population, prevalence estimates for medical anxiety are as high as 7%, and estimates of behavior management problems range from 9% to 11% (Van Horn et al. 2001). Overt emotional and behavioral distress often reflects children's efforts to avoid frightening and unpleasant situations and serves as a protective response to an external threat (Van Horn et al. 2001). Such reactions can range from verbal expressions of discomfort to resistance, physical protest, and refusal to cooperate. Fear and behavioral distress can interfere with the delivery of safe, efficient care for these children (Van Horn et al. 2001). Negative medical experiences also increase the likelihood of behavioral distress during subsequent health care encounters (Siegel and Smith 1989).
Assessing coping is complicated by the fact that different people involved in a health care encounter may have different perspectives on what is the most desired outcome. Parents may focus on minimizing observed distress in a child, whereas health care providers may focus on maximizing compliance (Rudolph et al. 1995). Notably, anxiety may not always emerge as overt behavior problems in the clinical setting. Only 60% of children who reported significant medical fear displayed uncooperative behaviors during treatment (Rudolph et al. 1995). Many youngsters may become withdrawn and uncommu nicative when faced with anxiety-provoking situations; thus, the seemingly cooperative patient actually may be overwhelmed with anxiety. As a result of these factors, having multiple sources of information on whether a coping response is adaptive is often the best method.
Medical hospitalization is associated with a diverse group of stressors. In addition to any distress associated with particular procedures and the discomfort they may cause, hospitalization is a uniquely challenging experience for children and adolescents because it involves loss of privacy and independence, separation from caregivers, and disruption of important daily routines (R.H. Thompson 1986). Considerable evidence indicates that hospitalization is associated with changes in patients' behavior, subjective assessments, and physiological indicators, as well as their perceptions of fear or pain, psychometric indices, and in some cases cognitive functioning (e.g., R.H. Thompson 1986). Classic studies in this area have found that hospitalization results in increases in separation anxiety, sleep anxiety, and aggression toward authority (Vernon et al. 1966). Of these, separation anxiety has been the most effectively addressed over the past several decades (R.H. Thompson 1986). Rooming-in and unlimited visitation, now the norm, are associated with better in-hospital child adjustment and more developmentally appropriate behavior while hospitalized (Brain and Maclay 1968; Shanley 1981). However, disruption of daily routines and sleep patterns caused by hospital procedures is common and may have important consequences for adjustment and behavior.
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