**3. Interdisciplinary care protocol for pediatric surgery at HCFMRPUSP**

This protocol was structured on a 2002 survey that aimed specifically to evaluate parents' understanding of their child's illness and the surgical procedures to be performed. We sought to investigate what were the principal doubts, fears, fantasies, and anxieties experienced by parents with regard to the risks and the diagnosis, as well as the hospitalization itself.

This work was carried out in order to understand what were the preconceived notions of the general population and also to assess the level of understanding and anxiety in the parents, before and after hospitalization of the child. In children, we analyzed changes in behavior before and after hospitalization, assembling comparative measurements.

The results of this study show data that compare to the related literature, where one can observe, through research tools, that:


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

Therefore, when the whole family can be prepared and supported by a psychological

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

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

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

This protocol was structured on a 2002 survey that aimed specifically to evaluate parents' understanding of their child's illness and the surgical procedures to be performed. We sought to investigate what were the principal doubts, fears, fantasies, and anxieties experienced by parents with regard to the risks and the diagnosis, as well as the

This work was carried out in order to understand what were the preconceived notions of the general population and also to assess the level of understanding and anxiety in the parents, before and after hospitalization of the child. In children, we analyzed changes in behavior

The results of this study show data that compare to the related literature, where one can

• Maternal anxiety was significantly reduced, by around 30% on average, one month after the surgery when the mother received psycho-affective care and guidance before and during the surgical procedure of her child. Mothers without this care and guidance display an average reduction of 8% in levels of anxiety. These data point to a conclusion that psychological intervention leads to a better adjustment in the way that the mother/caretaker represents and copes with the illness, which she consequently passes

• The mothers' levels of informed understanding, measured by correct information about the diagnosis, prognosis, and care for the child, before and after the surgery, were much more comprehensive in the group receiving psychological treatment, at 80% about activity restrictions after surgery and 100% about home care, while these figures respectively, were 50% and 40% in the group of mothers who did not receive guidance.

intervention, damage to the child's behavior and the family's anxiety can be reduced.

pre-operative preparation for the child and family before a medical intervention.

**3. Interdisciplinary care protocol for pediatric surgery at HCFMRPUSP** 

before and after hospitalization, assembling comparative measurements.

is done as much for the children as for their caregivers.

treatments and proposed procedures.

recovery, can be managed.

hospitalization itself.

on to the child.

observe, through research tools, that:

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 guided in an interdisciplinary manner.

• 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 hospitalization and possible separation from their protective parental figures.

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 to be taken in the hospital itself.

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

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 in a more global way.

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 submitted.

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 professionals.

Following the chapter is an outline of the protocol for psychological preparation of the presurgery child that is used at HCFMRPUSP.

Interdisciplinary Model of Attention for Children Undergoing Hospitalized Surgical Procedures 171

For these sessions, verbal instructions, didactic play materials, such as teaching material understandable to laypeople or hospital toys, and real hospital equipment are used as technical resources that may promote desensitization to procedures that may occur during

The handling of these materials is stimulated so that the real medical procedures will have been previously simulated in a play environment, seeking to promote desensitization of

Also provided are clarifications of the doubts and eventually presented inappropriate illusions. As part of the psychological intervention process, the most anxious parents and children visit the pediatric pre-anesthesia room of the surgery center and also the recovery room, where they receive a demonstration and explanation of the procedures that will occur

If the child experiences any difficulty in interacting with the medical staff, returns are scheduled weekly or biweekly, except in the case of an emergency surgery, until the child is able to recover from its fear and illusions and interacts appropriately with the team during

What occurs, therefore, is an adaptation of the child to the members of the team and to the hospital equipment through successive exposure, as well as a systematic desensitization by reciprocal inhibition, through relaxation technique training, in the cases where the child exhibits resistance to being examined or to remaining calm in the hospital environment.

When an emergency or urgent surgery is required, the child is hospitalized and this procedure of desensitization to the team and the treatment is performed intensively in the infirmary.

The psychologist works together with the interdisciplinary team, both on an outpatient basis

• Pre-operative group therapy that guides and prepares patients and parents for surgery; • Therapy for families and patients suffering from syndromes and malformations;

• Orientation and guidance for children and parents with difficulty accepting or

• Clinical therapy for children and adolescents who complain of daytime and nocturnal

• To guide and inform parents and patients about the disease and the procedures to be

• To create awareness of the emotional family aspects that can interfere with adherence to pediatric treatment and to improve the quality of life of the patient and the family.

The following are used as educational materials for working with children and families:

understanding processes, procedures, diagnoses and/or prognoses;

enuresis, encopresis, chronic constipation, and colon management; • Guidelines for parents for the management of their children's behavior. The specific objectives of the orientation and psychological counseling are:

• To promote desensitization to the procedures and to the hospital setting;

performed during the surgery and hospitalization;

**4. The psychological focus on interdisciplinary care in pediatric surgery** 

potentially anxiety-inducing situations that parents and children will experience.

the doctor visits and on the day of the surgery.

there, which are presented by the team's psychologist.

and in the infirmary.

The following take place in the clinic:

its evaluations and clinical procedures, which are often invasive.

Table 1. Protocol for psychological preparation of the pre-surgery child - HCFMRPUSP

Also assessed during this meeting are the issues of the child's global development, and necessary referrals are made to ensure the best possible neuro-psycho-motor development. Only after all these issues have been met and forwarded to the appropriate clinical followup services can the child be discharged from the Pediatric Surgery Interdisciplinary Team.

When the child has an organic impairment that requires surgical treatment, the care of the team, in addition to that which is listed above, also includes an interdisciplinary reception and guidance where the illness, procedures, processes, treatments and invasive interventions are clarified in simple and didactic terms, first by the medical team and later by the psychological team.

In this context, parents/caregivers and children are guided through questions about the child's health, the treatment processes, and the hospitalization. During this first meeting of the child to be operated on, a psycho-emotional assessment of the parents and the child about the diagnosis, the pre-operative, operative, and post-operative procedures, and the hospitalization is performed in order to explain and reduce any doubts or possible negative fantasies regarding the experience.

It is often the case that this work is not concluded after only one session, and returns become necessary so that the staff, the child, and the parents are all aware, accepting, and comfortable with the procedures and its possible risks and benefits.

The process of Psychological Intervention is applied to the child and its parents through psycho-educational guidelines, or information for caregivers and children.

For these sessions, verbal instructions, didactic play materials, such as teaching material understandable to laypeople or hospital toys, and real hospital equipment are used as technical resources that may promote desensitization to procedures that may occur during the doctor visits and on the day of the surgery.

The handling of these materials is stimulated so that the real medical procedures will have been previously simulated in a play environment, seeking to promote desensitization of potentially anxiety-inducing situations that parents and children will experience.

Also provided are clarifications of the doubts and eventually presented inappropriate illusions. As part of the psychological intervention process, the most anxious parents and children visit the pediatric pre-anesthesia room of the surgery center and also the recovery room, where they receive a demonstration and explanation of the procedures that will occur there, which are presented by the team's psychologist.

If the child experiences any difficulty in interacting with the medical staff, returns are scheduled weekly or biweekly, except in the case of an emergency surgery, until the child is able to recover from its fear and illusions and interacts appropriately with the team during its evaluations and clinical procedures, which are often invasive.

What occurs, therefore, is an adaptation of the child to the members of the team and to the hospital equipment through successive exposure, as well as a systematic desensitization by reciprocal inhibition, through relaxation technique training, in the cases where the child exhibits resistance to being examined or to remaining calm in the hospital environment.

When an emergency or urgent surgery is required, the child is hospitalized and this procedure of desensitization to the team and the treatment is performed intensively in the infirmary.
