**2. How pediatric illness can interfere with the family dynamic**

Illness represents a modification of the bio-psycho-social scheme in a very particular and individual way, known in healthcare literature as one of the main factors that affect anxiety levels, quality of life, and individual behavior.

In the case of children, it is emphasized that they are in the process of building their own representations of reality and they do so through the summation of all their experiences.

Within the many objective and subjective lived experiences in the developing child's life, the importance of the relative and reactive models provided by adults during the child's early social environment stands out. The younger the child, therefore, the greater the influence of the behavioral patterns and coping mechanisms displayed by the child's adult references.

In the case of illness, which is not represented by any distinctive cognitive or affective form, the child is strongly influenced by the actions of those individuals who provide it with emotional support because these adults are significant role models who will utilize their own prior associations to deal with the new reality of their child's health.

The manner in which children therefore deal with this new reality is oftentimes reflective of their parents' coping mechanisms and the way their parents deal with the anxiety that stems from fear and uncertainty about their child's diagnosis/prognoses.

The new reality creates uncertainty about how, and if, these adults will or will not be capable of reasonably and appropriately recoding the experience of surgery and/or hospitalization for their children to understand.

For parents, the expectation surrounding the responsibility they feel to maintain the health and wellbeing of their children transforms the surgical procedure into a trigger of extreme anxiety.

• To promote the understanding, development and acceptance of invasive procedures

• To help understand the cognitive and affective aspects of disease perception and their influences on the quality of life of patients and their families, supporting the diagnosis

Based on these objectives, the Pediatric Surgery Team of the University Hospital of the Faculty of Medicine of Ribeirão Preto of the University of São Paulo (HCFMRPUSP) developed a protocol of integrated care for patients and their families. Through this protocol, all children and families who will experience a surgical procedure are treated in consultation with an interdisciplinary team composed of surgeons and psychologists in order to provide guidance and explanation of the possible conflicts related to the surgery for

This model was developed from concepts described in several papers cited in the international literature, especially Canada, USA, France and China, which aimed specifically at the orientation of these patients for the procedures they will be undergoing, desensitization to invasive procedures, child-parent coping strategies, treatment and

Illness represents a modification of the bio-psycho-social scheme in a very particular and individual way, known in healthcare literature as one of the main factors that affect anxiety

In the case of children, it is emphasized that they are in the process of building their own representations of reality and they do so through the summation of all their experiences.

Within the many objective and subjective lived experiences in the developing child's life, the importance of the relative and reactive models provided by adults during the child's early social environment stands out. The younger the child, therefore, the greater the influence of the behavioral patterns and coping mechanisms displayed by the child's adult references. In the case of illness, which is not represented by any distinctive cognitive or affective form, the child is strongly influenced by the actions of those individuals who provide it with emotional support because these adults are significant role models who will utilize their

The manner in which children therefore deal with this new reality is oftentimes reflective of their parents' coping mechanisms and the way their parents deal with the anxiety that stems

The new reality creates uncertainty about how, and if, these adults will or will not be capable of reasonably and appropriately recoding the experience of surgery and/or

For parents, the expectation surrounding the responsibility they feel to maintain the health and wellbeing of their children transforms the surgical procedure into a trigger of extreme

and treatment compliance, thus providing greater progression

**2. How pediatric illness can interfere with the family dynamic** 

own prior associations to deal with the new reality of their child's health.

from fear and uncertainty about their child's diagnosis/prognoses.

hospitalization for their children to understand.

anxiety.

and hospitalization

both the child and the family.

prognosis, as well as interdisciplinary interaction.

levels, quality of life, and individual behavior.

The child's exposure to the risks of a hospitalization or surgery may induce negative fantasies and fearful reactions in both the parents and the child, exacerbating a natural reaction of anxiety and possibly causing a dysfunctional or pathological reaction of anxiety, and consequently a possible behavioral disruption.

The difficulty in understanding the procedure to be performed on the child, or even the hospital context to which the child will be exposed, the possibility of injury, loss or separation from the child, the anesthetic risk, and especially the fear of prognosis are some of the reasons these parental feelings are evoked.

For the infant, who is still in full development of its impressions, the principal sentiment is fear of the unknown, the pain, and the risk of separation from its attached adults, such as the mother.

Upon admission, everything surrounding the child is new and often scary. The child finds itself in a new routine with environmental and social restrictions and is often exposed to procedures that cause pain and/or discomfort.

These potentially anxiety-inducing changes are more intense during hospitalization due to the environmental restrictions, the hospital routine, and the prognosis, among other factors.

However, the process becomes more complex during surgery. There will also be an invasive intervention that includes anesthetic procedures, being that various studies show that surgery, and anesthesia in particular, are stimuli that trigger stress and anxiety because they can be symbolically associated with the fear of loss.

These factors may lead to behavioral changes in the child during and after hospitalization, such changes being more frequent in children who have not constructively addressed and coped with the stress they experienced.

In pediatric surgery, anxiety can be observed both in the child and in the parents, so that parental coping techniques, the representation of their anxiety and consequently the manner in which they deal with the child, can help or hinder the team's work and the child's recovery.

Very anxious parents exacerbate their child's inappropriate behavior, often hampering treatment and even the child's prognosis. For this group, with greater difficulty in coping with fear and anxiety, the child's behavior often changes during and after hospitalization, encouraging behaviors that are disturbing, such as nail biting and enuresis, and emotional, such as tantrums and night terrors. The same changes can also occur in the parents.

Note that empowering both children and adults to face and cope with the illness and proposed surgical procedure provides a way to deal with the information and can reduce fears and the implicit risks of a hospitalization. It is known that the quantity and quality of information received by the family and by the patient influence their trust in the team and consequently reduce anxiety and behavioral changes, which improves adherence to treatment.

In this way, we emphasize the idea that when information and psycho-emotional support are provided to patients and their families there is often an improvement in the acceptance of the proposed procedures and, especially, an increased confidence in the team.

Interdisciplinary Model of Attention for Children Undergoing Hospitalized Surgical Procedures 169

• The frequency of unwanted children's behavior such as bedwetting, nail biting, insomnia, night terrors, and overuse or re-attachment of comfort objects (pacifier, bottle) was also lower in the group of children who were given therapeutic space to express their concerns and be guided in a more appropriate coping mechanism to deal with the fear of

In this way, it was determined that the reception and guidance of the caregivers and the children is beneficial for the family, which produces a more relaxing work environment for the professional, which in turn also provides for fewer minor complications, due to the parents' better understanding of appropriate post-operative homecare and of the measures

Therefore, since 2002, this model protocol has been used by the interdisciplinary pediatric surgery team at HCFMRPUSP, with constant improvements made with respect to the integration of the group for the best possible care for the child and family and seeking to

In this model of care, all children entering the Department of Pediatric Surgery at HCFMRPUSP after a medical screening to assess their clinical needs are referred for a psychological evaluation so that their psycho-emotional and social needs can be perceived

The first meeting assesses the parents' and the child's previous understanding of the health issue and the need for clinical or surgical treatment. Also assessed are the psycho-emotional resources for coping with clinical questions and hospital situations to which they will be

When the child's visit to the hospital requires only clinical, and not surgical, procedures, the child and its family are evaluated by a psychologist in their understanding of the diagnosis, treatment, and prognosis, as well as their methods of coping with the particular situation.

During this assessment, the family group receives additional information about ways to manage the child's behavior in order to favor the treatment and are offered, when necessary, invitations to join support groups for chronic illnesses or individual counseling when the child and/or parents present difficulties in accepting the course of action proposed by the

Following the chapter is an outline of the protocol for psychological preparation of the pre-

promote a less aversive process for those involved in pediatric surgery.

hospitalization and possible separation from their protective parental figures.

guided in an interdisciplinary manner.

to be taken in the hospital itself.

in a more global way.

submitted.

professionals.

surgery child that is used at HCFMRPUSP.

Further, the adequacy and retention of the information relayed by the pediatric surgeons, of a total of 40 general questions about the treatment, displayed a 67.5% satisfactory response rate in the group that was treated with psychological intervention, whereas the group that only received the usual guidance displayed a 30% satisfactory response rate. The same was true for the unsatisfactory response rate, where the control group who received no further guidance answered 22.5% of questions unsatisfactorily, demonstrating inadequacy in the care of the children, while the psychologically guided group did not offer any inadequate responses. Attention should be paid to the potential risks in the post-operative home-care of children whose families were not cared for and

This work is done in order to allow patients and their parents to understand the context of their clinical situation with detailed quantitative and qualitative information about the treatments and proposed procedures.

Therefore, when the whole family can be prepared and supported by a psychological intervention, damage to the child's behavior and the family's anxiety can be reduced.

This procedure is done by encouraging better a better compliance with the treatment as a whole, which shows that parental anxiety and pediatric behavioral changes, recognized in literature as the main factors that influence a child's health during the post-operative recovery, can be managed.

The work of this team, carried out by a clinical psychology specialist professional in conjunction with surgeon colleagues, all looking for a better pediatric recovery, confirms and reinforces the literature about the importance of interdisciplinary work in planning a pre-operative preparation for the child and family before a medical intervention.

Thus, we present the protocol that is necessary for providing comprehensive interdisciplinary care to the hospitalized child, especially in the case of a surgery. This work is done as much for the children as for their caregivers.
