ANXIETY RELIEF 1

The Role of Play Therapy in Reducing Anxiety of Hospitalized Children

Emily Canavarros

College of Nursing, University of South Florida

REDUCING ANXIETY USING SOUND 2

Abstract

Clinical Problem: Hospitalized pediatric patients are at high risk for developing both temporary

and long-term anxiety due to various circumstances arising during hospitalization. Untreated

anxiety facilitates the development of a plethora of mental health issues later in life, further

emphasizing the importance of proper and timely anxiety management.

Objective: The objective of this synthesis is to evaluate the effectiveness of play therapy in

reducing hospitalized children’s anxiety. PubMed, ResearchGate, and the National Center for

Biotechnology Information were searched to find randomized controlled trials (RCT) and other

contributing clinical guidelines related to the use of play therapy in reducing anxiety. The key

search terms used were “play therapy RCT”, “anxiety”, and “pediatric hospitalization”.

Results: Pediatric patients who had received play therapy ended their stay with significantly

lower levels of anxiety. These results extended to patients admitted for surgical procedures and

were found to be valid during both pre- and post operative periods. Summative results also

indicated that play therapy was more effective than music therapy in lowering anxiety levels of

pediatric patients. Anxiety correlation between parent and child was also measured. Means of

measurement included vital signs and physiological markers as well as scales of anxiety (i.e.,

Hamilton Scale of Anxiety). Play therapy proved to be an effective and non-invasive method of

anxiety management and of prevention of further distress.

Conclusion: Through the analyzation of the collective randomized controlled trials and clinical

guidelines, therapeutic play was deemed a holistic and effective means of alleviating anxiety.

The therapy is unique in that it aids in both prevention of further complications and in immediate

distress. Further research indicating specific effects on each age group and the developing mind

would aid in deducting further conclusions.

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Using Play Therapy in Pediatric Patients to Reduce Anxiety

Children are most vulnerable to the destructive consequences of hospitalization. Due to

their limited emotional intelligence and dependence on others, they are far more likely to be

impacted by the sudden change in environment and health status (Rokach, 2016). Anxiety has

been identified as the most reported symptom in hospitalized children (Chhillar et al., 2020).

When treating physical ailments, healthcare professionals must face the psychological factors

accompanying them. Play therapy has been implemented to combat the heightened levels of

anxiety experienced by children during their hospital stay. With each study came a unique focus.

The first study mentioning the importance of the environment of the play space, the second with

an emphasis on play therapy during surgical procedures, and the third comparing play therapy

with art therapy. All studies deducted the same conclusion: therapeutic play undeniably aids in

the anxiety reduction of hospitalized children.

Literature Search

PubMed, ResearchGate and NCBI were used to access randomized controlled trials

(RCT) and other studies analyzing the benefits of therapeutic play during pediatric

hospitalization. Key search terms included “play therapy RCT”, “anxiety”, and “pediatric

hospitalization”. The publication years searched were 2008 to 2022.

Literature Review

Three RCTs and one clinical guideline were utilized to determine the effectiveness of

play therapy in reducing the anxiety of hospitalized children. The first analyzed RCT expanded

on the role of the environmental changes involved in therapeutic play. It was found that utilizing

an environment perceived to be safe by the child was crucial to the therapeutic process. The

study identified therapeutic play as a method of creative expression, diversion and of effective
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coping (Chhillar et al., 2020). The study also expanded on the developmental influence of play

and emphasized the importance of implementing such interventions on a vulnerable child

suffering from anxiety. The study separated males and females ages 6-12 using a random

sampling technique. In total 60 patients were utilized for the study (n=60). The control group

consisted of 30 patients (n=30), as did the intervention group (n=30). Anxiety was measured

using the Hamilton scale (a numeric rating of symptoms of anxiety), with parents and caretakers

appointed with collecting the data. Patients in the experimental group received play therapy

sessions from a child life specialist, while patients in the control group were given routine care.

The study was organized in its documentation of the medical conditions surrounding each

participating patient’s hospital visit. The RCT ultimately concluded that there was far less

anxiety experienced by those who had participated in play therapy (p=0.001). The study was

strong in its selection of patients using the Simple Random sampling technique. However,

researchers neglected to collect anxiety levels prior to the intervention, therefore lacking crucial

initial assessment data. In addition, the control group was not appropriate, as most children in the

control group had higher baseline levels of anxiety than those in the intervention group.

In the second study, children specifically hospitalized for surgical procedures were

studied. The study focused on the effectiveness of therapeutic play in preparing these children

for surgery. Parental anxiety and affect were found to heavily influence children’s anxiety levels.

Parents generally had difficulty assuming their role as caretaker whilst managing their own

feelings of stress and anxiety pre-operation (Li et al., (2008). These findings further emphasized

the power of play therapy in disrupting this harmful chain effect. Participants were monitored

during a 13-month period in a surgical unit using the integrated model of anxiety, one that

measures anxiety through perceptual-motor performance. The control group received routine
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care on the preoperative assessment day. The experimental group received therapeutic play

interventions performed by nurses approximately one week pre-operation, with the caretaker

present. The Chinese version of the State Anxiety Scale for Children (CSAS-C) along with

physiological markers of anxiety such as blood pressure and heart rate were analyzed before and

after the surgical procedure. Out of 203 participants ages 7-12 (n=203), 106 were in the control

group (n=106) and 97 in the intervention group (n=97). The results confirmed the hypothesis,

suggesting play therapy decreases pre- and postoperative anxiety in children (p=.03). The study

also expanded on the common theme of play therapy as a means of education. Specifically,

instructive play demonstrating surgical technique was effective in lowering anxiety levels. This

begs the question of whether the explanation of the surgical procedure or the play therapy itself

was the leading factor driving the anxiety reduction. The study excelled in ensuring that both

groups had similar baseline clinical variables. The control group had the surgical procedure

explained in detail, eliminating any doubt that play therapy itself sparked the anxiety reduction.

The study did however lack diversity, as it had less than half the amount of female participants

than males.

The third randomized controlled trial introduced a new variable as a means of

comparison. The therapeutic effects of art therapy in hospitalized children were dissected and

compared to the effects of play therapy. The study expanded on the more immediate effects of

anxiety: impacting length of hospital stay and even quality of nursing care (Bhoi et al., 2021). It

was concluded that play therapy was more effective than art therapy in lowering participant’s

anxiety levels. A randomized controlled parallel group trial was conducted and a questionnaire

was used for anxiety assessment. The sample size comprised of 66 children (n=66) ages 2-4. Art

and play therapy were performed on two separate experimental groups for 15 minutes daily,
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lasting for 3 days. The control group received routine daily care. Each group was given a pre-test

questionnaire for anxiety assessment. All three groups completed a post-test. The study

concluded that while both forms of therapy were more effective than just standard care, play

therapy most alleviated anxiety. The study’s strength lied in its attention to the demographic

information of participants, such as race and socioeconomic status. The study fell short with its

limited age range of focus.

The implementation of pediatric therapeutic play by child life specialists was further

highlighted in the utilized clinical guideline (Percelay et al., 2014). The clinical guideline

focused on the impact of these services, as observed in over 400 hospitals in the United States.

All hospitals implemented structured therapeutic play, varying with age. Therapeutic play was

described as an integral component of the patient-and-family-centered health care system. This is

apparent in the clinical guideline’s mission of promoting development of children while

minimizing adverse effects of hospitalization that effect both the child and family. The

information offered by the clinical guideline and other supporting research emphasized the

importance of the findings of the RCTs. Implementation of anxiety reducing measures,

particularly therapeutic play, are crucial in developing positive patient outcomes.

Synthesis

All sources and studies indicated that therapeutic play was integral in managing anxiety

in pediatric hospitalized patients. All studies highlighted the lasting effects of temporary anxiety,

emphasizing the need for immediate anxiety management for long term positive outcomes. The

studies all emphasized the parental role in anxiety development and were all keen on the

educational effects of therapeutic play. All findings impacted patient care through reducing the

length of hospitalization, increasing satisfaction rates of care, and preventing possible future side
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effects stemming from periods of extreme anxiety and distress. Evidence from the utilized

clinical guideline, Percelay et al. (2014), outlined the implementation of play therapy in various

hospitals. Evidence from the first RCT demonstrated that play therapy greatly reduces anxiety

levels in hospitalized children (p=0.001) Chhillar et al. (2020). The second RCT proved that

children undergoing surgical procedures responded positively to therapeutic play used for

anxiety reduction (p=.03) Li et al. (2008). The last RCT demonstrated that not only was play

therapy effective in lowering anxiety levels in hospitalized children, but that it was also more

effective than art therapy in doing so (p=0.001) Bhoi et al. (2021). There appears to be a lack of

research regarding specific age groups and developmental phases that benefit most from play

therapy. Most research on the topic extends until the age of twelve and fails to offer any

marketed difference in the chemical structure of the brain that might prevent the effectiveness of

therapy from extending past a certain age.

Clinical Recommendations

While evidence appoints play therapy as an effective anxiety reducing technique, it has

yet to become a standard treatment across every hospital in the United States. Research

regarding therapeutic play appears to have taken a broad and generalized approach to the

therapy, neglecting to expand on play varying with age and medical condition. Specific activities

and guidelines in play therapy would likely offer a more evidenced-based approach. The

evidence-based findings of the various studies surrounding the topic have sparked physicians,

nurses, psychologists and social workers alike to implement care for the emotional needs of

hospitalized children across the country (Rokach, 2016). Now equipped with extensive research

on the topic, registered nurses may begin to implement the educational and communicative
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strategies that comprise therapeutic play. Nurses are encouraged to undergo training to be best

equipped for formal and informal therapeutic play and general therapeutic technique.
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References

Bhoi, P., Das, N., Sahoo, P., Bhaktiswarupa, S. (2021). Effectiveness of art therapy vs. play

therapy on level of anxiety among hospitalized children. Turkish Online Journal of

Qualitative Inquiry (TOJQI), 12(10), 4863-4873.

https://www.tojqi.net/index.php/journal/article/view/8573/6084

Chhillar, R., Dabas, P., & Dular, S. (2020). Effectiveness of play therapy on anxiety among

hospitalized children in selected hospital, Greater Noida: An RCT. European Journal of

Molecular & Clinical Medicine, 11(7), 6653-6667. https://ejmcm.com/article_9428.html

Li H.C., Lopez V. (2008). Effectiveness and appropriateness of therapeutic play intervention in

preparing children for surgery: A randomized controlled trial study, Journal for

Specialists in Pediatric Nursing, 13(2), 63-73. https://doi.org/10.1111/j.1744-

6155.2008.00138.x

Percelay, J. (2014). Child Life Services, American Academy of Pediatrics, 133(5), 1471-1478.

https://doi.org/10.1542/peds.2014-0556

Rokach, A. (2016). Psychological, emotional and physical experiences of hospitalized children,

Clinical Case Reports and Reviews, 2(4), 399-401. https://oatext.com/pdf/CCRR-2-

227.pdf