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Death Anxiety In Leukemic Children
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Content
DEATH ANXIETY IN LEUKEMIC CHILDREN
by
John Joseph Spinetta
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Psychology)
June 1972
INFORMATION TO USERS
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University Microfilms
300 N orth Z e e b R oad
Ann A rbor, M ichigan 48106
A X erox E d u catio n C om pany
72-26,056
SPINETTA, John Joseph, 1938-
DEATH ANXIETY IN LEUKEMIC CHILDREN.
University of Southern California, Ph.D., 1972
Psychology, clinical
University Microfilms, A X E R O X Company, Ann Arbor, Michigan
(c) Copyright by
John Joseph Spinetta
1972
THIS DISSERTATION HAS BEEN MICROFILMED EXACTLY AS RECEIVED
UNIVERSITY O F SOUTHERN CALIFORNIA
TH E G RADUATE S C H O O L
U N IV ER SITY PA R K
L O S A N G E L E S. C A L IF O R N IA 9 0 0 0 7
This dissertation, written by
John. Joseph.. Spine.tfca.............
under the direction of h.& JH .. Dissertation Com
mittee, and approved by all its members, has
been presented to and accepted by The Graduate
School, in partial fulfillment of requirements of
the degree of
D O C T O R O F P H IL O S O P H Y
Dean
Date.
June 1972
DISSERTATION COMMITTEE
/ ' ^ S / Chairman
PLEASE NOTE:
Some pages may have
indistinct print.
Filmed as re c e iv e d .
University Microfilms, A Xerox Education Company
ACKNOWLEDGMENT
For their assistance in the completion of this
dissertation, I extend my appreciation to Drs. Ali
Banuazizi and A. Steven Frankel. I am grateful to Dr.
James Kahan for his aid both in the design of the disser
tation and in the final data analysis, and the co-chairman
of my dissertation committee, Dr. Albert Marston, for his
encouragement and assistance throughout the project.
I wish to express my gratitude to Dr. Myron Karon,
Mrs. Natalie Issner, and the Hematology Staff of Childrens
Hospital of Los Angeles for their cooperation, and the
staff of the Division of Psychiatry for sharing with me
their years of experience.
I am indebted to Drs. Howard Hansen and Daniel
Hayes of the Divisions of Psychiatry and Oncology of
Childrens Hospital of Los Angeles, and the National Insti
tutes of Health, Clinical Cancer Training Grant #CA08128,
for financial support in the final year of the project.
My sincerest appreciation is extended to the
nursing staff of Four-West at Childrens Hospital of Los
Angeles for continuing support and encouragement throughout
the project, and to the parents and children for what they
have taught me, both by word and example.
I can only begin to verbalize my feelings of
appreciation to Dr. David Rigler, my mentor and advisor,
committee chairman and close personal friend, for his many
thoughtful hours spent in guiding, encouraging, and sup
porting me throughout both the difficult and the rewarding
times.
Lastly, my complete and continual gratitude and
love go to my wife, Pat, for her extensive aid in the
details of the project, from the original concept formation
to the data transcription, writing, re-writing and proof
reading, and for the type of support and encouragement that
no one else can give.
TABLE OF CONTENTS
ACKNOWLEDGMENTS.................................... ii
LIST OF TABLES.................................... vi
Chapter
I. INTRODUCTION .............................. 1
II. THE RESEARCH PROBLEM..................... 12
The Normal Child and D e a t h ............. 12
Infancy and Toddler Period . . 14
Pre-School Years ..................... 15
Early School Y e a r s ................... 18
Preadolescent and Adolescent Period . . 23
Summary........................... 24
The Fatally 111 Child and Death......... 25
The Research Problem................... 35
Projective Test, Pictures (PIX) .... 39
Projective Test, Three-Dimensional
(3D) 41
Hospital-Anxiety (HOSP) and
Home-Anxiety (HOME) ................. 43
Measure of PersonalSpace ............. 46
First and Subsequent Hospital
Admissions.......................... 49
Measure of Field Dependence-
Independence ....................... 50
Summary of Hypotheses ................... 55
III. METHOD.................................... 57
Subjects................................ 57
Sampling Method......................... 60
Procedure................................ 62
Instruments.............................. 63
i v
Chapter
Pictures................................ 64
Projective Test, Three-Dimensional
(3D).................................. 65
Hospital-Anxiety (HOSP) and Home-
Anxiety (HOME) ....................... 69
Measure of Field Dependence-
Independence .......................... 70
Other Sources of Information............. 71
IV. RESULTS.................................... 73
Hypothesis One . . . ..................... 73
Hypothesis T w o ............................ 75
Hypothesis Three ......................... 76
Hypothesis F o u r .......................... 78
Hypothesis F i v e ......................... 83
Hypothesis Six . . . ................... 91
Hypothesis Seven .......................... 96
V. DISCUSSION.................................. 100
Measures of Anxiety Relating to the
Hospital................................ 104
Measures of Personal Space . . . ......... 120
Measure of Field Independence ........... 122
Conclusions.............................. 124
REFERENCES.......................................... 128
APPENDICES.......................................... 140
A. INK SKETCHES OF PICTURES USED IN
PROJECTIVE T E S T .......................... 141
B. SCORING SYSTEM— STORIES................... 143
C. FLOOR GRID FOR MEASURE OF PERSONAL SPACE . . 148
D. STATE-TRAIT ANXIETY INVENTORY FOR
CHILDREN.................................. 150
E. THE CHILDREN'S EMBEDDED FIGURES TEST .... 153
F. MISSING SCORES............................. 156
G. INCIDENTAL D A T A ........................... 160
H. RAW DATA.................................... 175
v
LIST OP TABLES
Table Page
1. Subject Data.................................. 58
2. Summary of Means and Standard Deviations for
Anxiety Scores on Projective Test, Pictures . 74
3. Summary of Analysis of Variance for Anxiety
Scores on Projective Test, Pictures .......... 74
4. Summary of Means and Standard Deviations for
Anxiety Scores on Projective Test,
Three-Dimensional ............................ 77
5. Summary of Analysis of Variance for Anxiety
Scores on Projective Test, Three-Dimensional . 77
6. Summary of Means and Standard Deviations for
Scores on STAIC-State, Hospital-Anxiety * . . 79
7. Summary of Analysis of Variance for Scores on
STAIC-State, Hospital-Anxiety ............... 79
8. Summary of Means and Standard Deviations for
Scores on STAIC-Trait, Home-Anxiety ........ 80
9. Summary of Analysis of Variance for Scores on
STAIC-Trait, Home-Anxiety ................... 80
10. Summary of Means and Standard Deviations for
Difference Scores between Hospital-Anxiety
and Home-Anxiety, HOSP Minus H O M E ........ 82
11. Summary of Analysis of Variance for Difference
Scores between Hospital-Anxiety and Home-
Anxiety, HOSP Minus HOME.......... 82
12. Summary of Means and Standard Deviations for
Measures of Personal Space Usual ............. 85
13. Summary of Analysis of Variance for Measures
of Personal Space Usual ..................... 87
v i
Table Page
14. Summary of Means and Standard Deviations for
Measures of Personal Space Like ............. 89
15. Summary of Analysis of Variance for Measures
of Personal Space Like ..................... 92
16. Correlations between Measures of Anxiety and
the Measure of Field Independence for the
Leukemic Children in the Study............... 97
17. Summary of Means and Standard Deviations for
Number Correct in the Measure of Field
Independence .................................. 99
18. Summary of Analysis of Variance for the
Number Correct in the Measure of Field
Independence .................................. 99
19. Summary of Means and Standard Deviations for
Use of the Phrase "I Don't Know" in
Projective Test, Pictures (PIX) ............. 162
20. Summary of Means and Standard Deviations for
Use of the Phrase "I Don't Know" in
Projective Test, Three-Dimensional ........... 162
21. Summary of Analysis of Variance for Use of
the Phrase "I Don't Know" in Projective
Test, Pictures (PIX) ............................ 1,63
22. Summary of Analysis of Variance for Use of
the Phrase "I Don't Know" in Projective
Test, Three-Dimensional ..................... 163
23. Summary of Means and Standard Deviations for
Number of Words Used in Story Telling in
Projective Test, Pictures (PIX) ....... 164
24. Summary of Means and Standard Deviations for
Number of Words Used in Story Telling in
Projective Test, Three-Dimensional ........... 164
25. Summary of Analysis of Variance for Number of
Words Used in Story Telling in Projective
Test, Pictures (PIX)............................165
v i i
Table Page
26. Summary of Analysis of Variance for Number
of Words Used in Story Telling in
Projective Test, Three-Dimensional .......... 165
27. Summary of Means and Standard Deviations for
Latency Scores in Story Telling in
Projective Test, Pictures (PIX) ............. 167
28. Summary of Means and Standard Deviations for
Latency Scores in Story Telling in
Projective Test, Three-Dimensional .......... 167
29. Summary of Analysis of Variance for Latency
Scores in Story Telling in Projective
Test, Pictures (PIX) ............................168
30. Summary of Analysis of Variance for Latency
Scores in Story Telling in Projective
Test, Three-Dimensional ..................... 168
31. Summary of Means and Standard Deviations for
Blocking Responses in Story Telling in
Projective Test, Pictures (PIX)................. 170
32. Summary of Means and Standard Deviations for
Blocking Responses in Story Telling in
Projective Test, Three-Dimensional .......... 170
33. Summary of Analysis of Variance for Blocking
Responses in Story Telling in Projective
Test, Pictures (PIX) ............................171
34. Summary of Analysis of Variance for Blocking
Responses in Story Telling in Projective
Test, Three-Dimensional ..................... 171
35. Correlation Matrix for 8 Variables, Cov.
Age-Grade................................. . 173
36. Raw Data for Story Telling Scores on
Projective Test, Pictures ................... 176
37. Raw Data for Story Telling Scores on
Projective Test, Three-Dimensional .......... 178
v i i i
Table Page
38. Raw Data for HOSP/ HOME and CEFT Scores . . .
39. Raw Data for Measures of Personal Space Usual
40. Raw Data for Measures of Personal Space Like .
41. Raw Data for Scores on Use of Phrase ”1
Don't Know," Number of Words, and Number of
15, 10-14, and 6-9 Second Pauses in
Projective Test, Pictures .................
42. Raw Data for Scores on Use of Phrase "I
Don't Know," Number of Words, and Number
of 15, 10-14, and 6-9 Second Pauses in
Projective Test, Three-Dimensional ........
180
181
182
183
184
CHAPTER I
INTRODUCTION
In 1960, Gorer referred to death as the new pornog
raphy, a topic to be discussed, as sex of old, privately
1
t
and in hushed tones, never to be mentioned to children, and
certainly out of bounds for study by psychologists. Feifel
(1959), in a preface to his edited volume on attitudes
toward death and dying, corroborated this popular view by
referring to death as a taboo topic. Yet, interest in the
study of death is gathering momentum among psychologists
and medical personnel alike. Recent research concerns have
focused on the study of the components of death and dying,
on an investigation of the fear of death, on an understand
ing of the stages in the development of the concept of
death, and on an appreciation of the components of the
grieving process.
In the past seven years, over fifteen books have
been written on the subject of the psychological aspects of
death and dying. A work by Hamovitch dealing with parents
and their fatally ill children at the City of Hope Medical
Center appeared in 1964. In 1965, an edited volume by
1
Fulton was published, as were books by Gorer, and by Glaser
& Strauss. In 1966, Vervoerdt published a study on atti
tudes toward dying. In 1967, four volumes appeared: those
of Grollman, Hinton, Mitchel and Quint. In 1968, Weisman
& Kastenbaum published. The following year the findings of
Kubler-Ross, of Kutscher, and of Pearson became available.
In 1970, Schoenberg, Carr, Peretz & Kutscher published
their edited volume on all aspects of the dying and griev
ing process. The same year, a book by Easson appeared,
relating his experiences with dying children. Kastenbaum &
Aisenberg in 1971 detailed their studies of death and
dying. Karon & Vernick, who had written articles in 1965
and 1968, are writing a volume containing their years of
experience with children dying of leukemia.
Over 1500 articles have been written in the past
20 years on the psychological aspects of death and dying,
as is attested to by a rather thorough bibliography com
piled by Vernick (1970). Kalish (1965, 1969b) annotated a
bibliography of over 500 articles most directly related to
the grieving process.
Two periodicals have emerged that deal solely with
the issue of death and dying: Omega, and the Archives of
the Foundation of Thanatology.
What Gorer described in 1960 as a topic not to be
spoken of publicly and Feifel referred to as a taboo topic
has emerged as a subject of research interest among
psychologists and medical practitioners.
Many conflicts and uncertainties still exist
relating to the compassioned management of the dying
person, in determining methods and content of communication
with the terminally ill, and in determining the sources of
comfort most important to the dying adult patient (Kubler-
Ross, 1969; Schoenberg, et al., 1970). These conflicts and
uncertainties are magnified when one is dealing with the
dying child.
It has become increasingly evident to teachers of
pediatric medicine and nursing that the circumstances of
death and dying in young children are circumvented and
denied by both medical and nursing students (Lourie, 1963;
Lourie, Hatleberg, Guin & Leikin, 1961; Quint, 1967; and
Quint & Strauss, 1964). Observation of doctors and nurses
in pediatric settings reveals a progressive lessening in
both actual number of contacts and total time spent with
the child as the child's condition becomes more critical
(Bonine, 1967; Caplan, 1954; Erickson, 1965; Goldfogel,
1970; Klagsbrun, 1970; Tonyan, 1967; Wiener, 1970b;
Wodinsky, 1964).
As a child nears death, many professional personnel
tend to cope with their own anxieties by avoiding the
patient and family when both most need support (Binger,
Ablin, Peuerstein, Kushner, Zoger & Mikkelsen, 1969;
Lourie, et al., 1961; Solnit & Green, 1959; and Wiener,
1970b). Conversations about death with the child are
strikingly absent, and the child is often left alone to
deal with his fears, anxieties and uncertainties. Binger
and associates (1969) relate that the doctors, nurses, and
parents of a fatally ill child frequently try to shield
him from his diagnosis. As a result the child has no one
with whom he may talk over his serious concerns. Binger
and associates .lament that, whereas the dying adult can
express some of his feelings to his spouse, to mature or
respected friends, or to his clergyman or doctor, the
dying child may have to deal alone with his fears, concerns
and apprehensions, and also cope with his own inner scheme
of fantasies.
Solnit & Green (1963) speak of the adult's tendency
not to perceive the dying child's behavioral and verbal
communications about his own fears because of the anxiety
evoked in the adult by the dying child.
Karon & Vernick (1968) report that despite signifi
cant recent advances in the treatment of childhood leu
kemia, the disease is still almost uniformly fatal, a fact
which prompts many physicians to hide the diagnosis from
their young patients. Yet, despite these evasive efforts,
children can and do become aware of the seriousness of
their illness. As a consequence, they worry. They need
emotional support.
Binger and associates (1969) consider it a grave
5
error to think that a child over four or five years of age
who is dying of a terminal illness does not realize its
seriousness and probable fatality. Their experience has
repeatedly shown the converse to be true.
In a study of 56 children from nine to twenty,
Vernick & Karon (1965) find that, even with the younger
children, as soon as their physician gives the parents the
news of a diagnosis of leukemia, the child immediately
senses that he has something very serious. His entire
environment changes. The child quickly notices that the
people whom he had previously trusted are now keeping
something frightening from him.
Despite the efforts to shield children with fatal
illness from awareness of their prognosis, the anxiety of
meaningful adults is conveyed to them through the altered
emotional climate around them (Binger, et al., 1969);
Karon & Vernick, 1968; Vernick & Karon, 1965; Waechter,
1968).
The parents of young fatally ill children who do
not wish their child to be informed as to the nature of his
illness can find support from some pediatricians. Howell
(1967) claims that one of the ways to help the family fight
grief and despair is by challenging them to protect their
child from the knowledge that his lifespan is limited. In
her years of practice, Howell feels that there is no need
for a child to bear the burden of knowingly facing death.
6
She feels the parents can spare him this.
Evans & Edin (1968) back Howell by favoring the
alternative of shielding the child from the knowledge of
his impending death, and protecting him as much as pos
sible from such fears of death. They claim that parents
find it nearly impossible to face the fact that their days
with their child are numbered, and cannot face discussion
of the topic with the child.
An editorial in the Medical Journal of Australia
(1969) further supports this position, claiming that by
discussing a child's inevitable death with the child him
self, the physician may be unloading the responsibility for
emotional defense from his own shoulders to those of the
child. The editorial maintains that parents who find the
prospect of their child's imminent demise an intolerable
burden will gratefully accept and cooperate with this
silent approach.
There can be no simple answer to what to tell the
child, whether to tell him all, or only part, or nothing at
all. Answers to direct questions depend so much on the
child's age, on the beliefs of the parents, and the views
of the doctor.
Yet, despite the effort to shield the child from
awareness of a fatal prognosis, the child is extremely per
ceptive to the altered emotional climates both within his
home and within the hospital setting, and is very aware of
the false cheerfulness or evasiveness of those around him
(Binger, et al., 1969; Karon & Vernick, 1968; Rothenberg,
1967; Waechter, 1968).
Perhaps reliance on overt expressions of death
anxiety may give an incomplete or distorted picture of the
actual concerns of the fatally ill child. A child may not
yet grasp the concept of death in an adult fashion, but
may, nevertheless, have very real concerns about his fatal
condition which may cause him great anxiety. Fear, isola
tion, and the accompanying fantasies surrounding the future
may be far more painful than facing death, especially for a
younger child whose development has not yet allowed him to
become aware of the latter reality. Loss of human contact
and communication can certainly exaggerate fear and phys
ical discomfort.
Telling the child everything is unacceptable to a
great number of physicians who prefer to treat their
patient with the conviction that the central problem is
whether and when the child is going to get better (Evans &
Edin, 1968; Howell, 1967; Medical Journal of Australia,
1969). Children build their defenses to protect themselves
from too much pain, and if denial occurs, it should be left
undisturbed if it serves a protective function (Plank,
1964). The role of the doctor, according to Plank, is not
to help erect or destroy these defenses, through silence,
untruth, or too open an attitude, but rather to recognize a
child's defenses when the child uses them and keep the
bridge to reality open.
Yudkin (1967) adds his own professional insights in
stating that, although the child with a fatal illness may
not know that he is dying, he may, nevertheless, respond
predictably to unusual behavior by his parents, who do
know the prognosis. In spite of these evasive efforts,
children do frequently become aware that something serious
is wrong, and then they begin to worry. Often the fears
are about some fantasy that has little or nothing to do
with the reality of the situation as perceived by adults.
A child's concept of death varies with his age, and
so too does his anxiety about his illness (Binger, et al.,
1969; Schowalter, 1970; Waechter, 1968). If he grieves and
how he grieves is related to his maturation and point of
development. A child under the age of five has little con
cept of death. As the child matures, he begins to appre
ciate some of the facts about death, and gradually develops
a more realistic appreciation of the reality and permanence
of death. The limbo stage between lack of awareness and
full awareness is the age level from about six to about
ten. This is the period during which the child has some
appreciation of the fact of death, but has not yet come to
a full adult awareness of the concept.
The present study will examine the various levels
of anxiety experienced by children between six and ten
years of age at various points in their illness.
The main area of concern in this study is the ques
tion of how children with fatal illness face their future,
and how anxious they are about the progress of their
illness. How children face death depends on their devel
opmental capacity to understand its meaning, and, accord
ingly, the review of the literature in the following
chapter will concern itself both with the general develop
ment of the child's concept of death, and with the child's
reactions to his own approaching death as the result of a
fatal illness.
Though not dealing directly with the child's views
of his own impending death, there are many areas of con
cern around the topic of children and death that are of
related interest. References to these areas will be given
at this point both to aid further research and to delimit
the area of the study by pinpointing what the study will
not attempt to cover.
The topic of reactions of children to the death of
a parent or sibling is overviewed in Furman (1964, 1970).
Lourie (1963), Quint (1967), Quint & Strauss (1964),
Rothenberg (1967) and Zhiani-Rezai (1969) give attitudes on
death as viewed by the medical and nursing professions.
The impact of the death of a child on the family
circle is reviewed extensively in Cobb (1956), Gordon &
Kutner (1965), Kalish (1969a) and Wiener (1970a).
10
The issue of religion and the role it plays in
death and dying, both in adults and in children, is dis
cussed in Alexander & Adlerstein (1959), Fargues (1966) ,
Grollman (1967b), Jackson (1965, 1967), Klaber (1950),
Lester (1970), Lichtenwalner (1964), Moberg (1968), Riley
(1967), Sherrill & Sherrill (1951) and Wolf (1958).
The process of grief and mourning, both in children
and in adults, is given an excellent review in Siggins
(1966), and is covered extensively in Kutscher (1969) and
in Schoenberg, et al. (1970).
The role of the medical profession and the nursing
staff in the aid of the parent facing the death of a child
is very closely related to the topic of the study, and
therefore a more lengthy bibliography will be offered.
Some of the following articles also deal with children's
attitudes toward their own impending death, and will be
referred to in greater detail in the following chapter.
The list is placed here for ready reference. The most
helpful articles that deal with the medical and nursing
professions' aid of parents with fatally ill children are:
Bierman (1956), Binger, et al. (1969), Bozeman, Orbach &
Sutherland (1955), chodoff, Friedman & Hamburg (1964),
Evans & Edin (1968), Freedman (1969), Friedman, Chodoff,
Mason & Hamburg (1963), Hamovitch (1964), Hoffman &
Futterman (1971), Knudson & Natterson (1960), Lourie,
et al. (1961), Natterson & Knudson (1960), Oppenheimer
(1967), Orbach, Sutherland & Bozeman (1955), Plank (1964),
Richmond & Waisman (1955), Solnit (1965), Solnit & Green
(1959, 1963) and Toch (1964).
The present study will not concern itself with any
of the foregoing topics. The review of the literature in
the following chapter will deal only with the general
development of the child's concept of death, and the
child's reactions to his own approaching death as the
result of fatal illness.
CHAPTER II
THE RESEARCH PROBLEM
The task of this chapter will be threefold. First,
there will be a review of the literature on the attitudes
of normal children toward death, in order to establish a
base level.
Second, there will be a review of the literature
on children with a fatal illness and their attitudes toward
their own impending death, and a comparison of these
findings with the attitudes of normal children toward
death.
Finally, there will be an analysis of the general
problem of this study, as an outgrowth of the literature
review, followed by seven specific hypotheses.
The Normal Child and Death
How children face death depends on their develop
mental capacity to understand its meaning. The variety of
children's responses to terminal illness can be partially
understood as a reflection of their emotional and concep
tual development at a given age.
12
13
There is a close relationship between development
of ideas about death and intellectual development in
general (Kastenbaum, 1967; Piaget, 1929, 1955; Schowalter,
1970). It is necessary to appreciate how strongly the
child's concept of death is dependent upon the total
pattern of mental processes and resources available to him
at a particular stage of his development (Gesell & Ilg,
1946; Piaget, 1955). For example, the statement "I will
die" is a recognition of personal mortality involving a
complex integration of concepts, some of which are quite
abstract and all of which require a process of emotional
and mental growth. A full understanding of the statement
"I will die" requires self-awareness, logical thought
operations, conceptions of probability, of necessity and
causation, of personal and physical time, and of finality
and separation. The available evidence strongly suggests
that the joung child lacks almost all the mental operations
required to form the separate concepts which are integrated
into the recognition of personal mortality, with the
exception of the concept of separation. It is clear that
one cannot attain a well-developed concept of death without
also possessing the intellectual tools for comprehending
all the fundamental conditions of life.
The concept of death becomes established in most
children just before puberty or at the beginning of
puberty, about the age of 11 or 12 (Anthony, 1940; Gesell &
14
Ilg, 1946; Nagy, 1948; Piaget, 1929, 1955; and Solnit &
Green, 1963). At this time, the totality of his experi
ences, intellectual development and sense of time enable
the child to conceptualize the implications of inevitabil
ity. This awareness of inevitability as a real concept is
accompanied by other evidences of perceptual and intellec
tual development, such as awareness of constancy of size,
tecture and weight of inanimate objects (Anthony, 1940;
Gesell & Ilg, 1946; Piaget, 1929).
In order to estimate a child's vulnerability to the
fear of dying, it is necessary to understand the develop
mental steps and perspectives which lead to the final
establishment of the concept of death in an adult fashion
around the age of 11 or 12.
Four developmental periods usually discussed are
the infant and toddler period (first three years of life),
the pre-school period (three to five), the early school
years (six to about ten), and the preadolescent and adoles
cent period (after about 11). It is understood that these
attitudes and concepts do not change abruptly at a given
age but evolve gradually and with wide individual variation.
Infancy and Toddler Period
During the first two years of life, there is no
understanding of death (Anthony, 1940; Gesell & Ilg, 1946;
Ilg & Ames, 1955; Kastenbaum, 1967; Schowalter, 1970).
15
Granted this, certain experiences and behaviors of the very
young child seem, by observation of behavior and guessing
about its possible relevance to death, to imply a relation
ship to the state of non-being. Some psychoanalytically
oriented therapists interpret the very young child's
interest in games of disappearance and return as experi
ments with non-being or death (Maurer, 1966? Von Hug-
Hellmuth, 1965). But we are limited here to observing
behavior and guessing about its possible relevance to
death. What is known about the child under the age of
three is that the fear of separation from protecting, com
forting objects is present in its most terrifying intensity
(Bowlby, 1960a, 1960b, 1961). While death is not yet a
fact for the child under three, anxiety about separation is
all-pervasive.
Pre-School Years
Sometime between the ages of three and five, most
children first comprehend the fact of death as something
that happens to others (Anthony, 1940; Furman, 1964;
Schilder & Wechsler, 1934; Schowalter, 1970). At this
time, the concept of death is still vague, associated with
sleep and the absence of light or movement, and is not yet
conceived of as permanent. The concept of death remains
relatively stable in this vague way in children of this age
group, but compared to the toddler they are better able to
16
withstand and understand short separation (Safier, 1964;
Schilder & Wechsler, 1934; Von Hug-Hellmuth, 1965). Pos
sibly because they cannot yet understand or comprehend
death's permanency, children in this age group respond more
spontaneously and with less anxiety to questions about
death than do older children (Gartley & Bernasconi, 1967;
Safier, 1964). Life at this age may be attributed to any
thing that moves, and death is understood as the opposite
of life (Caprio, 1950; Gartley & Bernasconi, 1967), and is
often described as remote, dark and constricted (Piaget,
1929; Safier, 1964; Schilder & Wechsler, 1934).
SoInit & Green (1963) report that, Whereas the
child under the age of three or four equates death with the
absence of the human love object, the four and five year
old child is curious about burial, about the characteris
tics of dead animals and flowers, and about the accidental
features of death. It is in this stage of development that
the child experiences wishes and thoughts as magically
potent. To wish and want strongly carries with it the risk
that the thought will be carried out in action. The child
often wishes that the adults in his life would go away and
never return. Hence, the child's anguish and guilt when a
parent dies.
During this period, the child usually has a rather
impressive command of language (Kastenbaum, 1967; Piaget
1929, 1955). The pre-schooler believes that identity has
17
no limit in time. He does not yet grasp the concept of
final limits. He knows that periodically one's condition
changes. Somewhat in the same way as you sleep, and as
you wake, so you are made dead and return again to ordinary
life. Even while dead, you still live, although perhaps in
a more restricted style, as when asleep (Anthony, 1940;
Kastenbaum, 1967; Nagy, 1948; Piaget, 1929).
Nagy (1948), in her pre-World War II study of
Hungarian children, found that children between the ages of
three and five denied death as a final event. The state of
being dead is temporary.
During this early phase in the development of
thought, the child seems to regard death chiefly as a
separation, but in a less egocentric way than the toddler.
It is clear enough that the dead person or animal is not
here with us, and that is probably the most important fact
of death for the young child (Kastenbaum, 1967). Any
separation, especially from a parent, is likely to arouse
thoughts of death. lildren often cannot distinguish
between a short absence and a long or permanent separation.
But even the child in this age group seems to
recognize that death is something special, even though he
is not able to comprehend precisely what it is that makes
death so special. Alexander & Adlerstein (1965) demon-*
strated that children as young as five years showed more
emotional reaction to death words than to other types of
18
words. The emotional reactions were measured by the use of
the Galvanic Skin Response and by the length of delay
between hearing a word and offering a response to it.
While the five year old might not be able to formulate
what is an accurate concept of death, he nevertheless
responds to death stimuli in a special way.
There is general agreement that the child begins
with a matter-of-fact orientation. Death is accidental,
and the child himself will not die (Anthony, 1940; Gesell &
Ilg, 1946; Nagy, 1948; Schilder & Wechsler, 1934).
Early School Years
The early school years involve the child from
about the age of six to about the age of ten. The various
authors disagree as to the exact ages when the concepts
take form; some purposely leave their findings general and
not age-specific. Most caution that the attitudes and con
cepts of children do not change abruptly at any given age,
but evolve gradually and with wide individual variation.
Although generalizations about attitudes of children who
present such a wide range of behavior and development are
not rigidly age-specific and precise, nevertheless some
common agreement seems to emerge.
From approximately the age of six onward, the child
seems gradually to be accommodating himself to the proposi
tion that death is final, inevitable, universal and
19
personal. Many six and seven year olds seem to suspect
that their parents will die some day, and that the same
fate may be in store for them, but at some distant future.
The somewhat limited information seems to suggest that the
child acknowledges death as real, but real in an external
and distant sense (Anthony, 1940; Bender, 1953; Moellenhoff,
1939; Nagy, 1948; Schilder & Wechsler, 1934).
Nagy (194 8) has observed that between the ages of
five and nine, there is a strong tendency to interpret
death in anthropomorphic terms. Death is a person. Death
exists, but the children still try to keep it distant from
themselves. Only those die whom the death man carries off.
Death is an eventuality, outside of the child and not
general.
During the ages of six to about ten, the permanency
and universality of death gradually, if incompletely, make
their impact on the child (Schowalter, 1970). Death in old
age is grasped at first. The unnaturalness of childhood
death is also first understood at this age.
Piaget (1955) shows that children of this age group
attribute death to an external agent which causes the
organism to die or cease to move. Safier (1964) found
children between five and eight most reluctant to talk
about death, while Alexander & Adlerstein (1965) report
that these children respond more anxiously to words asso
ciated with death than do older age groups. Blanchard
20
(1926) reports that dreams about death become more frequent
at about age six.
It seems that the fear of death also makes it first
appearance at about age six, and that the child is horri
fied, confused and angered by the discovery (Schowalter,
1970).
Piaget (1929, 1955) views the ages of six to ten as
the time when logical processes begin to make their
appearance and the dominance of egocentrism declines.
Still, the child cannot reason from assumptions in which he
does not believe; he cannot reason about more than one
situation at a time, and his generalizations about situa
tions are not broad enough to cover all cases.
Gesell & Ilg (1946) detail the stages of develop
ment by the year. They find that the six year old is
becoming more aware of the meaning of death; he is acquir
ing the idea of death by violence, death as a condition
that results from killing. For the seven year old, the
death idea has become somewhat more personal. The seven
year old suspects both that someday he himself might die,
and at the same time denies that he will die. The seven
year old has a realistic curiosity about the objective
symbols of death: the coffin, burial, the cemetery. The
eight and nine year old progress from an interest in graves
and coffins and funerals to an interest in what happens
after death. Their comprehension is more general, and
21
there is the beginning of the acknowledgment that all men
must die.
Anthony (1940) reports that the six to nine year
old applies the concept of death to aspects of death not
logically or biologically essential, such as graves and
coffins. The nine-going-on-ten year old uses human refer
ences exclusively when speaking of death. He speaks of
death with an increasing objectivity and with the addition
of biological aspects, such as failure of heart and pulse,
inability to breathe, inability to move. But his concept
is still insufficiently universal to be considered a final
and adequate understanding of death.
Gartley & Bernasconi (1967) agree with the findings
of the authors mentioned above. A dead person for the nine
year old is distinguished by the fact that he is not
breathing and that his pulse cannot be felt. Death for the
nine year old is caused by car accidents, heart attacks,
drowning, and cancer. The concept is still not suffi
ciently universalizedc
In a 1966 study, Peck explored the development of
children's thinking about death and examined the influence
of chronological age, mental age or I.Q., and social class
on that development. She chose 24 male children for each
year of a six-year span from three-and-a-half to nine-and-
a-half. Of the 24 children in each age group, eight were
selected with low I.Q.'s (75-92), eight with average I.Q.'s
22
(94-109), and eight with above average I.Q.'s (114-133).
Peck used four different stages associated with develop
mental levels: no understanding of death (level I), a
limited understanding of what death means (level IX), a
differentiated but not yet abstract and logical concept of
death (level III), and a fully developed concept of what
death means (level IV). She used a questionnaire specif
ically developed to assess children's concepts of death.
Peck found that the development of the concept of
death was unmodified by the social class position of the
children's family or by actual experience with death or
equivalents of death. She also found that the development
of children's thinking about death does indeed vary with
I.Q., and that this variation occurs between children of
average and of high I.Q., but not between children of low
and of average I.Q.
Peck found that some of her more intelligent
children arrived at an understanding of the concept of
death at an age younger than either the Nagy or Anthony
populations, but for the most part her findings agree with
those of Nagy and Anthony. A child under ten is beginning
to come to grips with the concept of death, but has not yet
attained a well-developed and universal understanding of
death.
23
Preadolescent and
Adolescent Period
Most 10-going-on-ll year olds seem to make a
transition in both emotional and intellectual development
that allows them to come to an understanding of death as a
final and inevitable outcome of life. Around this time,
children begin to make a close approximation to the adult's
view of the living and the non-living (Huang & Lee, 1945;
Kastenbaum, 1967; Klingberg, 1957; Russell, 1940).
Piaget (1955) suggests that as the child approaches
adolescence, about the age of 11 or 12, he is equipped with
the intellectual tools necessary to understand both life
and death in a logical manner. The child achieves a phase
of objective relativism and can now use logical thought
processes as well as results which are general in their
application. In fact, it is the questions the child asks
about death, both in plants, animals and with regard to the
human body, that cause the child to finally acquire the
notion of statistical causality or chance, and allow him to
develop the phase of objective relativism.
At about the age of 10 or 11, then, the fact of the
universality of death and the permanence of death finally
becomes comprehensible. The child now has an almost adult
capacity to understand death. There is a more universal
application of the concept of death, with the inclusion of
logical and biological essentials (Anthony, 1940; Nagy,
1948; Safier, 1964; Solnit & Green, 1963).
Gesell & Ilg (1946) report that the 10 or 11 year
old accepts death as a natural phenomenon, and accepts the
fact that all men must die. He does not limit his interest
to the external symbols of death, but now thinks of life
as having a physiological basis: nutrition, growth, blood,
and breathing. Death comes when these essentials fail.
Death is a negation of the biological process of life.
Gartley & Bernasconi (1967) concur with the find
ings of the above authors, adding that, while the child of
11 now understands that he himself must die, his own death
is still something that will probably not occur for a long
time.
Summary
There seems to be general agreement that a child
under five lacks almost all of the mental operations
required to form the concept of death, even in a beginning
manner, with the exception of his understanding of the con
cept of separation. By the time a child reaches the age of
11 or 12, the concept of death is fairly well established.
In between, during the ages of six to about ten, is a stage
during which the child has some appreciation of the fact of
death, but has not yet come to a full adult awareness of
the concept.
The Fatally 111 Child and Death
How does all this apply to the child who has been
diagnosed with a fatal illness? How does the fact that a
child is going to die affect his attitude toward and under
standing of death? Does a fatally ill child have any
awareness of his own impending death? Does he have an
understanding of death and what it implies at an age
younger than the normal child?
In most of the related studies reported in the
literature, the emphasis has been placed on the impact of
death on the family circle/ and on interviewing and aiding
the parents concerned. Only incidental clinical observa
tions of the children were reported in most of the studies,
and only a few studies have been reported that were specif
ically designed to ascertain children's attitudes toward
their diagnosis or impending death.
We will briefly review those studies, and relate
them to the attitudes toward death of the normal child.
The first major study speaking directly to the
issue of the children's own feelings toward their fatal
illness was that of Knudson & Natterson (1960). Knudson &
Natterson separated the reactions of the terminally ill
child into three phases: under six, when fears of separa
tion are paramount; from six to ten, when fears related to
physical injury and mutilation are foremost; and after
about ten, when fears of impending death become more
26
obvious. Knudson & Natterson indicate that this finding
suggests that separation, mutilation and death fears are
separate and distinctive.
In another study written the same year, Natterson &
Knudson (1960) propose that in the years between six and
ten, the manifestations of death fear are vague and
evanescent, and that expressed anxiety in this age level is
generally related to intrusive or painful operating pro
cedures. Children over the age of ten did manifest a fear
of death, communicating to personnel a fear of dying that
was urgent, pervasive and persistent, taking definite
precedence over other fears. Although the children seldom
asked questions about their death, the staff somehow felt
that the children probably knew of their own impending
death. The staff did not have this feeling with the
children under ten. Reactions which led to this conclusion
included anxiety, depression and withdrawal on the part of
a child which deepened with the death of another child on
the ward.
In order to preserve the other children's will for
recovery, Friedman and associates (1963) often felt it
necessary to deny or bypass mention of the death of a hos
pitalized companion with the same illness. The authors
felt it best to bring up the matter again at a later time.
Indicating that, even though children build defenses to
protect themselves from too much pain, they also want
27
somehow to be told the truth, Friedman and associates see
the role of the doctor and other paramedical personnel to
be one of being in close contact with the children's
thinking and anxieties, and finding opportunities to talk
about death when needed. It is a challenging task to
recognize children's defenses, and at the same time to be
honest and open to questions the children may ask about
death, or about their illness. Yet, Friedman and asso
ciates feel that the children may be saved greater anguish
and their affirmation of life strengthened when this
challenge is met with intelligence, intuition and compas
sion.
Vernick & Karon (1965) describe a program of work
with 51 children hospitalized for the treatment of acute
leukemia. As a result of their observations and conversa
tions with those children, most of whom were over nine
years of age, they concluded that despite evasive efforts
on the part of physicians to hide the diagnosis of leukemia
from the young patients, children can and do become aware
of the seriousness of their illness. Vernick & Karon felt
that as a consequence of their awareness, coupled with a
lack of communication, the children worry. Repeating their
views in a later paper, Karon & Vernick (1968) stated that
the children became even more worried when confronted by a
conspiracy of secrecy and were greatly relieved by the
opportunity to discuss their concerns with a sympathetic
I
28
adult. They also found that children tend not to ask
questions of the staff or their parents, but, instead,
wait for adults to show a readiness to anticipate and deal
with their concerns.
Only three studies report anxieties in children
under five, other than the Vernick & Karon study. Knudson
& Natterson (1960) report separation anxiety in children
below three years of age. Both Solnit & Green (1963) and
Kliman (1968) report cases of four year olds conveying
knowledge of their own impending death. What such knowl
edge of death means to a four year old is difficult to
determine from the studies.
In a study of 48 children, Richmond & Waisman
(1955) reported that the fatally ill patients rarely mani
fested an overt concern about death, but reacted to their
illness with an air of passive acceptance and resignation.
The ages of the children are not mentioned in the study.
Morrissey (1963a, 1963b, 1965) reports on 50 hos
pitalized leukemic children, 16 of whom he judged to be
aware or suspicious of the fatal nature of their illness.
Morrissey's results supported the earlier findings of
Knudson & Natterson (1960) that separation anxiety is
dominant in children under five, mutilation anxiety in
children six to nine, and death anxiety in children over
nine.
Yudkin (1967) supports the thesis that the fear of
I
29
death is usually remote in the fatally ill child aged three
to seven. At this age, the child is usually more afraid
of discomfort and pain than of the idea that he might die.
The older child gradually develops a more realistic appre
ciation of death. Yet, on the whole, fear of death is
relatively remote for a child under ten. Yudkin cautions,
however, that often those attending a sick child may remain
unaware that a particular child is frightened of dying,
either because it seems inconceivable to them, or because
they will not allow themselves to consider the possibility.
Kliman (1968) reiterates the position that reliance
on overt expression of death anxiety or fears may give an
incomplete and distorted picture of the actual concerns of
the fatally ill child. Childhood communications about
death in general are faulty. Young children find it diffi
cult to express their feelings openly about such topics as
death, and thus are often thought by their adult investi
gators to be lacking in anxiety. This expressive diffi
culty must be considered when thinking of children's
emotions and attitudes toward death in the face of their
own impending demise. Much may be underground, states
Kliman, and reports of children not having death anxiety
may really only be reports of children's lack of expression
of those anxieties.
The identical point is brought out by Binger and
associates (1969), in a study on the emotional impact of
childhood leukemia on the patient and his family. Although
a child's concept of death varies with his age, interviews
conducted by the authors disclosed that most of the chil
dren above four years of age, although not directly told of
the diagnosis, presented evidence to their parents that
they were aware of the seriousness of their disease and
even anticipated their premature death. Even though the
parents of the older 14 children tried to shield them from
the diagnosis, during the course of the illness 11 of these
14 indicated their sense of their own impending death.
Younger children, though not expressing fear of death per
se, manifested concern about separation, disfigurement, or
hurt. Only two of the teenagers were told that they had
leukemia. Both of the families involved reported a more
meaningful relation with their child because of their
frank discussion of the diagnosis and the open communica
tion within their families.
Binger and associates report that as parents
attempted to protect their children from the concerns of
the illness, older leukemic children attempted similarly to
protect their parents. The children who were perhaps the
loneliest of all were those who were aware of their diag
nosis but at the same time recognized that their parents
t
did not wish then to know. As a result, there was little
or no meaningful communication, and there was no one with
whom the child could openly express his feelings of
31
sadness, fear or anxiety.
Binger and associates conclude from their study
that it is a grave error to think that a child over four or
five years of age who is dying of a terminal illness does
not realize its seriousness and probable fatality. The
question becomes not whether to talk about the diagnosis,
since the child usually senses it anyway, but rather how to
let the child know that his concerns are shared and under
stood and that there is willingness to talk about his con
cerns with him. Adults and older siblings involved should
reassure the fatally ill child that everything possible is
being done for him, and that all are ready to help and to
communicate in any possible way to allay any apprehensions.
Although his approach is far from rigorous, Easson
(1970) expresses his feelings that the growing youngster
aged six to ten cannot avoid being aware that something
serious is happening to him. When the child of this age
level asks about the reality of his situation, he should be
told the truth in terms that he can use, to help allay his
anxieties.
Schowalter (1970) feels that it is during the ages
from six to ten that the concept of terminal illness first
makes its impact on a dying child, and that death anxiety
is greatest during this period. Along with the child's
understanding of death, the lack of comfort in his presence
of the staff and adults around him is also perceived by the
32
child, who in turn becomes even more anxious when communi
cation is not forthcoming. Schowalter warns of the im
portance in this age group that parents do not underesti
mate the child's possible awareness of the seriousness of
his condition. Allowing the child to discuss his fears
concerning his illness continues to be crucial in allaying
his anxieties.
In brief, then, there is a strong feeling that many
of the fatally ill children in the age group six to ten,
if not aware of their own impending death, are aware at
least that something serious is happening to them. For the
child under five, anxiety takes the form of separation
anxiety, fear of abandonment and loneliness. For the
fatally ill child six to ten years of age, the fear of
abandonment is replaced, in part, by a fear of bodily
intrusion and mutilation, and by the possible awareness of
his own death, or, at the least, the awareness that some
thing serious is happening to him. The youngster over ten
with a fatal prognosis seems to be almost universally aware
of and anxious about his own impending death, whether he is
told directly about his illness or is kept from open com
munication about his illness for whatever intention by
those around him.
These findings seem to be in agreement with the
earlier discussion of attitudes of normal children toward
death in their various stages of development. For the
33
child under five, fears of separation are paramount. For
the child from six to about ten, fears relating to physical
injury, intrusion into body integrity and mutilation are
foremost. After ten, fears of impending death become more
pronounced. In the years from six to ten, the manifesta
tions of death fear are vague and evanescent, and expressed
anxiety is generally related to intrusive or painful
operating procedures.
Of all the studies, one hypothesized the presence
of death anxiety in fatally ill children aged six to ten>
results quite contrary to the findings of the remainder of
the authors. In her study of death anxiety in fatally ill
six to ten year old children, Waechter (1968) tested the
results of the earlier studies by Knudson & Natterson
(1960) and Morrissey (1963a, 1963b, 1965), that separation
anxiety is dominant in children under five, mutilation
anxiety in children six to ten, and death anxiety in chil
dren over ten. Since Waechter's study was the most sys
tematic and well controlled study in the area of children's
attitudes toward their own fatal illness, and since her
results seem to be in opposition to the findings of earlier
authors, her study will be summarized in detail.
It was Waechter's contention that death anxiety is
present in children aged six to about nine. Using a set of
eight pictures, four from the Thematic Apperception Test,
and four specifically designed for her study, Waechter
34
requested a story for each picture from each of the 64
children in her study cohort, in an attempt to elicit
indirect and fantasy expression of the child's concern
regarding present and future body integrity and function
ing. She also administered to each child the General
Anxiety Scale for Children (GASC) designed by Sarason and
associates (1960).
Using four groups as independent variables
(fatally ill children, children chronically but not fatally
ill, children with brief illnesses, and normal non
hospitalized children), Waechter found that her fatal group
scored significantly higher both in the objective and in
the projective anxiety measures than did the other groups.
She found no significant difference between the groups with
a chronic or a brief illness, nor between the sexes. So
far, her results are in agreement with those of previous
authors, that fatally ill children show a high degree of
anxiety. However, contrary to the findings of Knudson &
Natterson (1960) and of Morrissey (1965), Waechter found a
higher degree both of death themes and concerns, and of
separation themes and concerns, than of mutilation concerns,
among the 16 fatally ill six-to-ten year old children in
her study.
The problem became clear. All of the previous
studies, both of normal children and of fatally ill chil
dren, pointed in the same direction. Children aged six to
35
ten years were not yet old enough to grasp the full meaning
of the concept of death. Fatally ill children in this age
group of six to ten were more concerned with intrusion into
their body integrity and functioning (mutilation) than
they were with death. Although Waechter did find a high
degree of concern with intrusion into body integrity in her
fatal group, she found a very high degree of concern with
and themes of death. Her findings contradict those of the
previous authors.
The Research Problem
The problem is clear. There is a contradiction.
It must be resolved. The aim of the present investigation
was: first, to verify or disprove Waechter's findings,
both by a partial replication of her study and by newly
devised techniques, and second, to do so with firmer con
trols and by taking her hypotheses several steps further.
It was the contention of the present investigator
that Waechter's findings that children aged six to ten
spoke often of death was in contradiction both to findings
by the majority of authors writing about fatally ill chil
dren, and to findings about the conceptual abilities of the
normal child in this age level.
Given the reluctance of medical and nursing per
sonnel and of parents to speak to the fatally ill child
about his illness, reliance on overt expressions of death
36
anxiety would give an incomplete or distorted picture of
the actual concerns of the fatally ill child. When these
overt expressions do not occur, it becomes a very simple
task to rationalize and say that the child does not speak
about death and, therefore, does not understand the seri
ousness of his illness. A child may not yet grasp the
concept of death in an adult fashion, but may, neverthe
less, have very real, concerns about his fatal condition
which may cause him great anxiety. Reliance by adults on
the child’s overt expressions of death anxiety may blind
them into a comfortable reluctance to communicate with the
child about his very real concerns. Fear, isolation, and
the accompanying fantasies surrounding his future may be
far more painful than facing death, especially for the
younger child whose development has not yet allowed him to
become aware of the latter reality. Loss of human contact
and communication can certainly exaggerate fear and physi
cal discomfort.
It is the contention of the present investigator
that reliance on overt expression of death concerns, shown
to be present by Waechter's findings, can lead to a denial
of the child's concerns when the child does not in fact
outwardly express death concerns. Although the child with
a fatal illness may not know that he is dying, he may,
nevertheless, respond predictably to unusual behavior by
his parents, who do know the prognosis. It is the
37
contention of the present study that in spite of evasive
efforts on the part of parents and of medical and nursing
personnel, children do frequently become aware that some
thing serious is wrong, and then they begin to worry.
Often the fears may be about some fantasy that has little
or nothing to do with the reality of the situation as per
ceived by adults. Waiting for the child to speak of death,
and not talking to him about his illness because he does
not speak about death, may well keep meaningful adults in
the child's environment from seeing the child's very real
concerns about the seriousness of his illness.
It was the purpose of this study to devise instru
ments to re-test Waechter's findings, hopefully to show
that, although fatally ill children may not speak overtly
of death, they nevertheless may have very real concerns
about the seriousness of the illness, concerns which far
surpass those of his non-fatally-ill hospitalized compan
ions.
The test protocol that was devised for the study
will be summarized here briefly, and then explained in
greater detail.
The test protocol consisted of the following four
parts: (a) four pictures depicting hospital scenes,
borrowed with Waechter's permission for inclusion in the
present study; (b) a three-dimensional replica of a hos
pital room, with a steel floor marked off in squares, with
38
magnetized dolls representing meaningful adults in the sick
child's environment (nurse, doctor, mother, father); (c)
an anxiety scale sorting out hospital-anxiety from home-
anxiety, and (d) a test used to explore personality differ
ences, also used as a distracting "game'' at the end of the
test proper.
Each child was asked to tell a story about each of
the four pictures in protocol (a), including in the story
what was happening and what was going to happen to the sick
child in each of the pictures. The stories were scored for
content relating to what we have termed a preoccupation
with threat to body integrity and functioning.
Each child was then presented with protocol (b),
the three-dimensional hospital-room replica, with a doll
representing a sick child in bed in the center of the hos
pital room. The testee was asked to describe the feelings
of the sick child. He was then asked to place each of the
four adult dolls (nurse, doctor, mother, father) into the
room, and to describe both what the person was doing in the
room, and the sick child's reaction to the person. A per
sonal space measure was taken of the distance of the place
ment of each of the adult figures from the sick child.
Next, the examiner read to each child each of the
40 questions in the anxiety scale, circling one of the
three possible answers to each question.
Finally, the examiner administered the Children's
39
Embedded Figures Test (CEPT), both as an exploratory
measure of personality differences, and to distract the
child from any anxiety that the protocol may have brought
out in him.
Details of the protocol and reasons for the inclu
sion of each part in the study are as follows.
Projective Test,
Pictures (PIX)
The first task of the study was to replicate
Waechter's study in part with firmer controls, using the
same four pictures specially designed for her own study.
With Waechter's permission, the four pictures were borrowed
for inclusion in the present study. Added controls to
reduce confounding effects in this part of the study were
as follows.
First, Waechter's fatal group was composed of 16
children with four different fatal illnesses (3 children
with leukemia, 6 with neo-plastic disease, 6 with cystic
fibrosis, and 1 with progressive septic granulomatosis).
It was decided to limit the present study to one type of
illness, leukemia.
Second, Waechter had gone to three different hos
pitals to achieve her population of fatally ill children.
It was decided to take both the fatally ill population for
the present study and the control subjects not only from
the same hospital, but from the same ward, with identical
40
nursing and medical personnel.
Third, Waechter administered the test to each child
in his own sick room. At times, the children were very
tired or under the immediate effects of medication, so that
in many instances she had to return several times in order
to complete the test protocol. It was decided in the
present study to administer the entire test protocol in a
separate room, a room set aside for the testing, and to do
so only when the child was able to leave his own room and
was willing to come and "play the games" with the examiner.
This latter procedure was envisioned as avoiding, to a
certain extent, the confounding effects caused by the types
of medication that would make a child tired, depressed, or
listless.
Finally, Waechter placed into her fatal group chil
dren who were newly diagnosed and those who had been in the
hospital many times for treatment of their illness. It was
decided in the present study to separate the children into
first and subsequent admissions, and to explore differences
between the two groups.
With these changes in the protocol, designed to
tighten the experiment and avoid possible confounding
effects, Waechter's study was partially replicated. A set
of four pictures (to be designated as PIX), borrowed from
Waechter for inclusion in the study, was shown individually
to each child in the study by the same experimenter, and
41
stories were requested in an attempt to elicit indirect and
fantasy expression of the child's concern regarding present
and future body integrity and functioning.
Details on administration are given in Chapter III.
The scoring system is outlined in the Appendix.
Besides re-testing Waechter's conclusion that
children aged six to ten years with a fatal illness
expressed a greater degree of death themes than of mutila
tion themes, the projective test, pictures (PIX) was also
administered in order to determine whether in fact children
with a fatal prognosis are more anxious than children for
whom the prognosis is not fatal. The first hypothesis,
accordingly, is as follows.
HYPOTHESIS ONE: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL RELATE STORIES THAT SHOW A
GREATER PREOCCUPATION WITH THREAT TO THEIR BODY
INTEGRITY AND FUNCTIONING THAN WILL CHILDREN WHO
DO NOT HAVE A FATAL PROGNOSIS.
Projective Test, Three-
Dimensional (3D) "
In order to give the children in the study ample
opportunity to express their feelings about the hospital in
as non-obtrusive a manner as possible, a new technique was
devised specially for the study. The present investigator
devised a three-dimensional replica of a hospital room,
18 x 11 x 7 inches, scaled one inch to one foot in the
real-life hospital room. The setting, vr.ith dolls and
furniture made to scale, was designed with a galvanized
steel floor marked off in one-inch squares. Magnets were
attached to the feet of the four-inch-high dolls, so that
they would stand erect when placed. A doll representing a
sick child was in a bed in the center of the room, and was
referred to throughout the study in the third person. The
testee was asked to describe the feelings of the sick
child. He was then asked to place each of the four adult
dolls (nurse, doctor, mother, father) into the room, and
to describe both what the person was doing in the room, and
the sick child's reaction to the person. Details of
administration are presented in Chapter III.
Each of the stories for the projective test, three-
dimensional (3D) was scored in the manner used for the pro
jective test, pictures (PIX), as outlined in the Appendix.
Besides being a further test of Waechter's findings regard
ing presence of overt expressions of death anxiety, the 3D
part of the protocol was administered as a further test
with a different instrument of whether or not children with
a fatal illness are more anxious about their hospitaliza
tion than children for whom the prognosis is not fatal.
The second hypothesis is as follows.
HYPOTHESIS TWO; CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL RELATE STORIES OF PLACED
FIGURINES THAT SHOW A GREATER PREOCCUPATION WITH
43
THREAT TO THEIR BODY INTEGRITY AND FUNCTIONING THAN
WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS.
During the administration of the test protocol,
a personal space measure was taken of the distance of
placement of each of the adult figures from the sick child.
The purpose of this measurement will be elaborated in
Hypothesis Five. Prior to the discussion of the personal
space measure, the use of objective anxiety scales will be
discussed.
Hospital-Anxiety (HOSP) and
Home-*Anxiety (HOME)
As part of her test protocol, Waechter presented
each child with a 45-question anxiety scale, the General
Anxiety Scale for Children devised by Sarason and associ
ates (1960). The questions looked for a yes or no re
sponse, and were an attempt to study general anxiety in the
children in the protocol.
The present investigator wished to sort out the
child's anxiety in the hospital from his anxiety in non
hospital-related situations, as the child himself viewed
his own feelings. Accordingly, the task became one of
finding an instrument that would allow the proposed
differentiation.
The instrument chosen for the task was the State-
Trait Anxiety Inventory for Children (STAIC), developed by
Spielberger (1970) from the adult version, the State-Trait
44
Anxiety Inventory (Spielberger, Gorsuch & Lushene, 1968).
In their 1968 publication, Spielberger and associ
ates outline in detail the various steps in the test
development process and the specific procedures employed
in the construction and selection of items for the state
and trait scales of the STAI. The authors beg b y
administering three widely used anxiety scales to 288
introductory psychology students at Vanderbilt University,
the IPAT Anxiety Scale (Cattell & Scheier, 1963), the
Taylor (1953) Manifest Anxiety Scale, and the Welsh (1956)
Anxiety Scale. A succession of 14 stages over a five year
period resulted in the reduction of the items to 40, a
series of 20 questions in each of the two scales.
The STAIC is a translation of the STAI into lan
guage more easily intelligible to a child.
The STAI and the STAIC are comprised of separate
self-report scales for measuring two distinct anxiety con
cepts, state anxiety and trait anxiety. The trait scale
consists of 20 statements that ask the subject to describe
how he generally feels. The state scale consists of 20
statements that ask the subject to indicate how he feels at
a particular moment in time, the moment usually being the
time the test is administered.
State anxiety is conceptualized as a transitory
emotional state or condition of the human organism that is
characterized by subjective, consciously perceived feelings
45
of tension and apprehension, heightened by autonomic
nervous activity. States may vary in intensity and fluc
tuate over time.
Trait anxiety refers to relatively stable indi
vidual differences in anxiety proneness, that is, differ
ences between people in the tendency to respond to situa
tions perceived as threatening. Trait anxiety attempts to
measure acquired behavioral dispositions, dispositions that
involve residues of past experience that predispose an
individual both to view the world in a particular way and
to manifest object-consistent response tendencies.
For the purpose of the study, the state scale was
used to determine the child's personal feelings toward the
hospital and hospital-related procedures. The set was
given the child to answer the first page of 20 questions
(state scale) in relation to how he feels when he is in the
hospital.
The trait scale was used to determine the child's
personal feelings generally. The set was given the child
to answer the second series of 20 questions (trait scale)
in relation to how he feels when he is at home.
The 40 questions of the two-part questionnaire
(hereafter referred to as HQSP and HOME, respectively) were
read to each child, with the examiner circling one of the
three possible answers to each question. Details for
administration are given in Chapter III.
46
The HOSP and HOME were administered in order to
determine whether in fact children with a fatal prognosis
are more anxious regarding hospital-related procedures
and/or regarding their life generally than are children for
whom the prognosis is not fatal. The two hypotheses that
flow from this part of the test protocol are as follows.
HYPOTHESIS THREE: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL EXPRESS MORE ANXIETY RELATING
TO THE HOSPITAL THAN WILL CHILDREN WHO DO NOT HAVE
A FATAL PROGNOSIS.
HYPOTHESIS FOUR: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL EXPRESS MORE GENERALIZED
ANXIETY RELATING TO NON-HOSPITAL SITUATIONS THAN
WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS.
Measure of Personal Space
Throughout the literature on fatally ill children,
there are statements by nursing and medical personnel and
by parents that, as the child's condition becomes more
critical, there is a progressive lessening both in actual
number of contacts and in total time spent with the child.
As a child nears death, many professional personnel tend to
cope with their own anxieties by avoiding the patient.
Many parents have ambivalent feelings: on the one hand,
they want to shower the child with all the affection they
can in his few remaining months or weeks of life; on the
47
other hand, they feel a growing separation of their feel
ings from the child, as if they were building a protective
wall for themselves for the time when the child's death
will actually occur. Conversations about death or about
the seriousness of his illness are not engaged in with the
child, and the child is often left alone to deal with his
fears, anxieties and uncertainties.
The measure of personal space was introduced into
the study in an attempt to measure this feeling of alone-
ness that the child is said to experience.
Human territoriality or personal space, an area of
man-environment relationships which has achieved recent
popularity (Altman, 1970; Guardo, 1969; Hall, 1959, 1966;
Lett, Clark & Altman, 1969; Little, 1968; Little, Ulehla &
Henderson, 1968; Meisels & Guardo, 1969; Sommer, 1969) can
be defined as the area immediately surrounding the indi
vidual in which the majority of his interactions with
others takes place. In a series of studies operationally
defining personal space in terms of the placement of human
figure statuettes, Little and associates (Little, 1965,
1968; Little, Ulehla & Henderson, 1968) found that several
factors modify the specific distances placed between
figures. Among the prime factors are the nature of the
interaction, the degree of acquaintance attributed to the
testee and the figurines, and the setting for the inter
action. In short, the figurines represent the situation as
48
viewed by the testee.
If, as the literature on the fatally ill child
suggests, parents and medical personnel, for whatever
reasons, tend to isolate the fatally ill child much more
than the child without a fatal prognosis, it would be of
interest to discover whether or not in fact the fatally ill
child would place dolls representing significant figures at
a larger distance on the average than non-fatally-ill
children. What is being measured is not the actual physi
cal distance of the adults in the real-life situation, nor
the number and frequency of contacts with the child. What
is being measured is the child's perception of the distance
of the adult figures. Since the parents and medical and
nursing personnel do not in fact stand any further away
from the fatally-ill child than they do from the other
children in the ward, what is being measured is the sick
child's perception of psychological distance. If the
actual distance adults stand does not change, but if fre
quency and duration of contact is lessened, and if, in
fact, there is an emotional withdrawal from the fatally
ill child, the measure of personal space is conceived of as
mirroring the child's perception of psychological distance.
It was with this intent that the measure of
personal space was introduced into the present study.
Details of administration are presented in Chapter III.
During the administration of the 3D part of the
49
test protocol, a measure was taken of the distance of
placement of each of the significant figures from the bed
in which the sick child in the replica is lying. The
measure is envisioned as determining whether in fact
children with a fatal prognosis perceive the significant
figures in their hospital life as in some way being further
away from them than would non-fatally-ill hospitalized
children. The hypothesis dealing with this measure is as
follows.
HYPOTHESIS FIVE: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL PLACE DOLLS REPRESENTING
MEANINGFUL ADULTS IN THEIR HOSPITAL ENVIRONMENT AT
A GREATER DISTANCE THAN WILL CHILDREN WHO DO NOT
HAVE A FATAL PROGNOSIS.
First and Subsequent
Hospital Admissions
Consultation with the hematology staff attending
fatally ill children at Childrens Hospital of Los Angeles
has helped in the formulation of the concept that fatally
ill children who are anxious on their first trip to the
hospital, but who may have been reassured by promises of
cure and who have subsequently been sent home/ befcome
increasingly anxious when they must return to the hospital
a second or third time.
It is in order to test the above observation that
the sixth hypothesis is devised.
HYPOTHESIS SIX: PREOCCUPATION WITH THREAT TO BODY INTEG
RITY AND FUNCTIONING, HOSPITAL-RELATED AND NON-
HOSPITAL-RELATED ANXIETY, AND PERSONAL SPACE
MEASURES WILL BE GREATER FOR CHILDREN IN SUBSEQUENT
VISITS TO THE HOSPITAL THAN FOR THOSE WHO ARE
VISITING THE HOSPITAL FOR THE FIRST TIME FOR THE
ADMITTING ILLNESS.
Measure of Field Dependence-
Independence
Even a carefully planned non-obtrusive measure of
anxiety might conceivably elicit underlying feelings of
anxiety in some very sensitive children, and might add to
an already present discomfort about the hospital and about
the illness. Accordingly, it was deemed appropriate to end
the test protocol with some type of "game" that the child
would find both pleasing and distracting.
It was also deemed to be in the best interest of
the study to find a "game" that might also lead to further
knowledge about the fatally ill child, while at the same
time providing the necessary and pleasant distraction.
The task became one of finding an instrument that
would serve the dual purpose of further exploration and of
distraction. The instrument chosen for this purpose was
the Children's Embedded Figures Test (CEFT), one of a
series of tests designed by Witkin and associates (1962) to
help identify the characteristics of a more or less
!
51
differentiated psychological state. Witkin and associates
define the objectives of their tests as follows.
In the course of the development of differentia
tion, a child identifies and internalizes particular values
and standards, which help determine his view of himself.
The child develops a growing sense of what he is like,
whether objectively correct or not, and how he is different
from or similar to others. Witkin and associates refer to
this development in self-concept as the achievement of a
sense of separate identity.
Formation of the self involves a more or less
simultaneous development of an inner core of experience and
the segregation of this core from the field. There is a
progression from an initial relatively unstructured state,
with segregation of the self from the environment at best
very limited, to a more structured state, with greater
segregation of self. The self becomes more differentiated
as it develops.
The achievement of a relatively differentiated
self implies that in the area of experience where the
person's own activities and attributes are the source,
experience is relatively articulated, analyzed and
structured, rather than global. During development, the
influence of the immediate context is reduced, and progress
toward differentiation is expressed in the increasing
articulation, analysis and structure of experience.
52
Witkin and associates have devised a series of
tests that place persons onto a continuum with the differ
entiated (field independent) at one end, and the less
differentiated (field dependent) at the other end.
Among the many measures of field dependence-
independence designed by the Witkin group, the CEFT is one
of the most convenient to use, and correlates very highly
with the more cumbersome measures. While some of the other
tests used to measure field dependence-independence require
elaborate paraphernalia, the CEFT is simple, and can be
administered as a pleasant "game" to children. Accordingly,
the CEFT was the Witkin measure decided on for use in the
present study.
One finding of Witkin is that persons who are
field independent are more capable of reacting to stress
with internalized values than with anxiety, repression, or
fear. The latter reactions are more typical of the field
dependent perceivers, who tend to react to stress situa
tions with a more manifest anxiety.
In contrast to these early findings of Witkin, some
investigators have ground to believe that in certain types
of situations, the field independent perceiver is the
person most likely to become anxious. In a 1971 volume on
neurosis, a work representing 25 years of research in col
laboration with Witkin on perceptual style, Lewis dis
covered that the phenomenological organization of self-in-
53
the-field influences whether or not a person undergoing
therapy is more likely to experience shame and helplessness
(typical of the field dependent) or guilt and certain forms
of anxiety (typical of the field independent).
The Witkin schema could be interpreted either way:
depending on one's view of field dependence-independence,
one could argue for higher anxiety in either type of
perceiver. However, it is very much in accord with Witkin
that the field independent perceiver is more capable and
adept at sorting out figure from ground, and thus more
capable of "seeing through" situations. It would seem
that, given an environment in which adults are trying to
conceal information from a child, the field independent
child would be the most capable of seeing through the adult
defenses, and of picking up subtle cues of anxiety from the
adults in his hospital environment. If in fact the adults
in the fatally ill child's hospital environment tend to
conceal from him the truth of his diagnosis and yet,
nevertheless, are highly anxious about the child's illness,
it would seem, in accord with Witkin's observations, that
the field independent perceiver would be the most capable
of sorting out the parents' true feelings.
On the other hand, if the parents of the non-
fatally-ill children are honest and open about the chil
dren's illnesses, it would seem that the field independent
chronically ill child would pick up from his environment
54
cues that show a lack of great anxiety, or at least, an
anxiety less than that picked up from parents of fatally
ill children.
If the parents of the chronically ill children do
not exhibit a great amount of anxiety, it is in accord with
Witkin's observations to presume that the field independent
child with a chronic but non-fatal illness will sense this
trust in hospital procedures and lack of great anxiety.
If, on the other hand, the parents of the fatally ill
child do exhibit a great amount of anxiety, it is in accord
with Witkin's observations to presume that the field
independent child with a fatal illness will sense this
anxiety, more so than will a field dependent child.
As an exploratory test of this concept, the follow
ing hypothesis has been devised.
HYPOTHESIS SEVEN: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WHO SCORE HIGHEST IN THE VARIOUS
MEASURES OF ANXIETY (PIX, 3D, HOSP, HOME) WILL ALSO
SCORE HIGHEST ON MEASURES OF FIELD INDEPENDENCE.
If the correlation proves significant, a less
anxiety-provoking measure will have been found to help
differentiate anxiety-proneness in the fatally-ill child,
and ultimately aid medical and nursing personnel to deal
with those children who perhaps may need more direct and
honest answers to questions relating to their very real
fears. The measure is merely exploratory, and not central
55
to the main hypotheses of the study.
Summary of Hypotheses
HYPOTHESIS ONE; CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL RELATE STORIES THAT SHOW A
GREATER PREOCCUPATION WITH THREAT TO THEIR BODY
INTEGRITY AND FUNCTIONING THAN WILL CHILDREN WHO
DO NOT HAVE A FATAL PROGNOSIS.
HYPOTHESIS TWO: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL RELATE STORIES OF PLACED
FIGURINES THAT SHOW A GREATER PREOCCUPATION WITH
THREAT TO THEIR BODY INTEGRITY AND FUNCTIONING THAN
WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS.
HYPOTHESIS THREE; CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL EXPRESS MORE ANXIETY RELATING
TO THE HOSPITAL THAN WILL CHILDREN WHO DO NOT HAVE
A FATAL PROGNOSIS.
HYPOTHESIS FOUR: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL EXPRESS MORE GENERALIZED
ANXIETY RELATING TO NON-HOSPITAL SITUATIONS THAN
WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS.
HYPOTHESIS FIVE; CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WILL PLACE DOLLS REPRESENTING
MEANINGFUL ADULTS IN THEIR HOSPITAL ENVIRONMENT AT
A GREATER DISTANCE THAN WILL CHILDREN WHO DO NOT
HAVE A FATAL PROGNOSIS.
HYPOTHESIS SIX: PREOCCUPATION WITH THREAT TO BODY INTEG
RITY AND FUNCTIONING, HOSPITAL-RELATED AND NON-
HOSPITAL-RELATED ANXIETY, AND PERSONAL SPACE
MEASURES WILL BE GREATER FOR CHILDREN IN SUBSEQUENT
VISITS TO THE HOSPITAL THAN FOR THOSE WHO ARE
VISITING THE HOSPITAL FOR THE FIRST TIME FOR THE
ADMITTING ILLNESS.
HYPOTHESIS SEVEN: CHILDREN AGED SIX TO TEN YEARS WITH A
FATAL PROGNOSIS WHO SCORE HIGHEST IN THE VARIOUS
MEASURES OF ANXIETY (PIX, 3D, HOSP, HOME) WILL ALSO
SCORE HIGHEST ON MEASURES OF FIELD INDEPENDENCE.
CHAPTER III
METHOD
Subjects
The subjects for the study were 50 children aged
six to ten years, all hospitalized on the fourth floor of
Childrens Hospital of Los Angeles, sometime between May
1971 and February 1972. Of the 50 children, 25 were hos
pitalized with a diagnosis of leukemia, while the remain
ing 25 were children with chronic but non-fatal illness,
matched as closely as possible to the fatally ill in age,
sex, race, and grade in school. An attempt was also made
to match the children as closely as possible in terms of
seriousness and amount of medical intervention, as well as
number of times in the hospital. Of the 25 children in
each of the two groups, nine were newly diagnosed, while
16 were in the hospital for a subsequent admission for the
same illness.
Table 1 presents the subjects by code number
(CODE), age in months (AGE), sex (SEX), grade in school
(GRD), number of times in the hospital (#-H), and diag
nosis.
57
58
TABLE 1
SUBJECT DATA
-
CODE AGE SEX GRD #-H DIAGNOSIS
A1 73 F 1 1 Leukemia
B1 70 F K 1 Pneumonia
A2 76 M 2 1 Leukemia
B2 82 M 1 1 Asthma
A3 78 M 1 1 Leukemia
B3 73 M K 1 Epiglottis
A4 81 F 1 1 Leukemia
B4 83 F 2 1 Anemia
A5 98 M 3 1 Leukemia
B5 95 M 2 1 Diabetes
A6 98 M 3 1 Leukemia
B6 98 M 3 1 Diabetes
A7 103 F 3 1 Leukemia
B7 103 F 3 1 Pneumothorax
A8 112 F 3 1 Leukemia
B8 118 F 4 1 Diabetes
A9 128 F 5 1 Leukemia
B9 129 F 5 1 Systemic Lupus Erythematosus
Cl 67 F K 9 Leukemia
D1 71 F K 3 Asthma
C2 68 M 1 2 Leukemia
D2 66 M K 2 Asthma
C3 74 M 1 2 Leukemia
D3 72 M K 2 Heart Murmur
C4 75 F 1 3 Leukemia
D4 76 F 1 5 Asthma
C5 78 M 1 5 Leukemia
D5 78 M 1 9 Dermatomyositis
C6 80 F 1 2 Leukemia
D6 84 F 1 4 Hypoglycemia
C7 80 M 2 2 Leukemia
D7 85 M 2 2 Asthma
C8 86 M 2 2 Leukemia
D8 84 M 2 2 Nephrosis
C9 89 M 1 2 Leukemia
D9 88 M 2 3 Sydenham’s Chorea
CIO 89 M 1 2 Leukemia
DIO 96 M 2 3 Nephrocalcinosis
Cll 95 F 3 2 Leukemia
TABLE 1— Continued
59
CODE AGE SEX GRD
#-:
Dll 96 F 2 4
C12 103 M 3 4
D12 106 M 3 2
Cl 3 104 F 3 2
D13 109 F 3 5
C14 113 M 4 3
D14 113 M 4 2
C15 126 M 5 4
D15 123 M 5 5
C16 128 M 5 3
D16 143 M 5 2
DIAGNOSIS
Congenital Heart Disease
Leukemia
Chronic Glomerulonephritis
Leukemia
Cranioplasty
Leukemia
Kyphoscoliosis
Leukemia
Phenylketonuria
Leukemia
Asthma
Mean Age =92.7 A = 94.1 B = 94.6
C = 91.1 D = 92.4
Mean Grade = 2.16 A = 2.33 B = 2.22
C = 2.13 D = 2.06
Mean Hospital
Stay = 2.52 A = 1.00 B = 1.00
C = 3.31 D = 3.43
Median Age = 88.8
Median Grade = 2.0
Median Hospital
Stay = 2.0
A
=
98.0 B
=
95.0
C
S
87.5 D
S
86.0
A
=
3.0 B
=
2.0
C 1.5 D 2.0
A 1.0 B
=
1.0
C
r =
2.0 D 2.5
60
Sampling Method
Since the relative number of children with fatal
illness in the age group six to ten is small, it was
necessary to accept each child in the age range who was
hospitalized with a diagnosis of leukemia. After obtain
ing clearance from the medical staffs, medical and nursing
administration and research committee of Childrens Hospital
of Los Angeles in February, March and April of 1971, the
study was begun in May, 1971.
Following admission of the leukemic child into the
hospital, contact was made with the child's parents for
permission to include their child in the study. Although
no parent approached denied such permission, three leukemic
children were not given the test protocol and were there
fore not included in the study. Discussion of these three
cases will be reserved for Chapter V.
After the parents had given permission, the examiner
approached the child, introduced himself on a first name
basis, and began to establish rapport. When the child was
able and willing to leave his room, often in a wheelchair
and inevitably with a bottle used for intravenous feeding
(IV) on a rolling stand, the examiner would take the child
to a room which was used throughout the study as the room
in which the test protocol was given.
The study was continued until 25 leukemic children
had been given the test protocol. The twenty-fifth child
61
was tested in February 1972, nine months after the study
was initiated.
Administration of the test to the non-fatally ill
children was conducted in a like manner. Following admis
sion of the child into the hospital, contact was made with
the child's parents for permission to include their child
in the study. No parent approached denied such permission.
After the parents of the chronically ill children
had given permission, the examiner approached the child,
introduced himself on a first name basis, and began to
establish rapport. When the child was able and willing to
leave the room, often in a wheelchair and, as in the case
of the fatally ill, often with an IV, the examiner would
take the child to the testing room.
All the children aged six to ten years who were
hospitalized with a chronic illness on the same ward as the
fatally ill children were presented with the test protocol.
Since the number of children with chronic illnesses far
surpassed those with fatal illness, 96 children with
chronic illness were given the test protocol during the
nine month period of the study.
When the study was completed, a list was drawn,
matching each of the fatally ill children as closely as
possible in age to the chronically ill children. Each of
the 25 fatally ill children were matched with from 2 to 4
chronically ill. This list was presented to a neutral
62
party, who was asked to select the best match for each of
the fatally ill children, using the criteria of age, sex,
grade in school, race, seriousness of illness, and amount
and duration of hospitalization. Where these elements did
not match exactly, the judge was asked to select the best
match in terms of the child who came closest in meeting the
majority of the criteria. The judge selected 25 of the 96
chronically ill subjects as the 25 to be used in the data
analysis.
Although two of the subjects chosen for inclusion in
the first admission chronic group (B) did not have a
chronic illness (Bl with pneumonia and B3 with epiglottis),
the judge selected these two for inclusion in the study as
best matches on all other criteria.
Procedure
Each child was brought to a room on the floor
directly across from the playroom. The testing room was
small and contained only a desk and two chairs, no windows.
This room was used as the location for the testing for all
of the children in the study.
In contrast to the study by Waechter, during which
she gave the test in the child's sick room, and often had
to return several times to finish the test protocol, the
present test protocol was administered in a separate room,
and only when the child was able and willing to come out of
63
his or her room to the test room and "play the games." The
entire test was administered in one sitting (about 20-30
minutes) to each of the children in the study cohort. The
use of the separate room was designed to eliminate at least
the gross effects of medication, for the children would
refuse to leave their own rooms to come and "play the
games" when they were feeling tired, depressed, or list
less.
Many of the parents asked to talk to the examiner
about personal issues, and the examiner did so, but only
after having administered the test protocol to the child in
question. Contact with the child other than the initial
introduction was avoided until after the test protocol,
when the examiner did spend quite a bit of time with most
of the children, both in their rooms and in the play room.
Instruments
The test protocol consisted of the four parts
referred to earlier: (a) (PIX) four pictures depicting
hospital scenes; (b) (3D) a three-dimensional replica of a
hospital room, with a steel floor marked off in squares,
and with magnetized dolls representing meaningful figures
in the sick child's hospital environment (nurse, doctor,
mother, father); (c) (HOSP and HOME) an anxiety scale sort
ing out hospital-anxiety from home-anxiety; and (d) (CEFT)
a distracting "game" at the end of the test proper, used to
64
explore personality differences. We will discuss each of
the four measures in detail.
Pictures
A set of four pictures was shown individually to
each child in the study by the same experimenter, and
stories were requested in an attempt to elicit indirect and
fantasy expression of the child's concern regarding present
and future body integrity and functioning, in the manner
used by Waechter (1968) in her study. The four pictures,
borrowed from Waechter with her permission for inclusion in
the present study, were specifically designed by her.
Picture 1 shows two boys in adjoining beds. Picture 2
depicts a small girl in a hallway outside a closed door,
with the words "Intensive Care Unit" written on the door.
Picture 3 shows a small child in bed, with a nurse nearby
at the stand with her back turned and her hands holding
something on the stand. Picture 4 depicts a child in bed,
with parents and a doctor outside the open door talking to
each other.
Instructions to the child were as follows: "Tell
me a story about this picture. What do you think is
happening in this picture? Make the story as exciting and
interesting as you can." After the child ended his or her
story, with each picture, further instructions were: "What
do you think is going to happen in the picture?"
The pictures were presented to each child in the
order listed. The stories were recorded on tape, and later
transcribed and scored. No time limit was set for the
child, and no prompting was given. In no case was it
necessary to break the testing sessions because of the
physical condition of the child. All four pictures were
administered at one sitting.
The framework of the scoring system used in the
study is based on the scoring system used by Waechter
(1968), as adapted from the scoring manual for the achieve
ment motive outlined by McClelland and associates (1958).
The total scoring procedure is presented in the Appendix.
The stories were scored independently by three
judges. Following discussion of differences in scoring,
the agreed upon reconciled score was subsequently used for
all categories. Disagreements were few and minor.
Projective Test, Three-
Dimensional (3D)
A three-dimensional replica of a hospital room was
specially designed for the study. The floor of the room,
18 x 11 inches, was covered with a piece of galvanized
steel to allow magnets to stick to it. Dolls four inches
in height were fitted with magnets on their feet so that
they would stand up straight when placed. There were four
dolls used in the study, one representing a nurse, one a
doctor, one a mother, and one a father, all meaningful
adult figures in the sick child's hospital environment.
There were two sets of dolls, one black and one white.
Throughout the testing, the white doctor and white nurse
were used, because these best represented the medical and
nursing personnel on the ward. The sick child was always
represented by a doll that was the sex and race of the
child being tested. The mother and the father dolls were
of the appropriate race.
Although there were many children in the study with
Spanish surnames, it was decided that the differences in
economic and educational backgrounds of the families did
not give sufficient unity for use of this factor as a
separate basis for matching. In the one case in which a
fatally ill child had been born in a Spanish-speaking
country, the child was matched to a control with a similar
background.
Within the hospital-room replica were a sick child
in a bed in the center of the room, a couch, a bureau, a
bathroom, a television set, and an IV stand. Each child
was presented with the three-dimensional hospital-room
replica, with the instructions: "Let's pretend this is a
hospital room, and that's a friend of yours, and your
friend is sick in the hospital. Can you tell me what you
see in the room?" After the child's answer, instructions
continued: "What is your little friend thinking about all
by himself (herself) in the hospital room?"
67
When the child finished this part of the story, he
was presented with a doll representing a nurse, with the
instructions: "Here comes the nurse. Can you put her in
the room where she usually goes?" After the child placed
the nurse into the room, instructions continued: "What
is the nurse doing in the room?" After the child answered
the question, instructions continued: "What is the nurse
thinking about?"
The identical instructions were used with the doll
representing the doctor, and with the two dolls represent
ing the mother and the father.
When all four dolls had been placed, instructions
continued: "What is your friend thinking about with all
those people standing around?"
After the child had answered this question, instruc
tions concluded: "Now, if you could put the people any
where you wanted in the whole room, where would you most
like the people to be?"
This final instruction ended this 3D part of the
protocol. Throughout the protocol, a personal space
measure was taken of the distance of placement of each of
the adult figures from the sick child in the bed. The
placement was recorded on a special page designed for the
study, a page marked off in grids identical to the grids
on the floor of the hospital-room replica. Placements were
subsequently translated into feet, one inch in the replica
68
representing a one foot distance. Since placement of the
subsequent dolls was inhibited by placement of the dolls
first presented, distance was not measured from the head of
the bed, but from the side of the bed. A mark was made on
the answer page one ''footM from the end of the bed. Any
placement beyond this point was marked as distance from
this point. Thus, a doll placed next to the bed, at any
point above the marked "one foot" line, might receive a
score, for example, of one-fourth foot. A doll placed at
the foot of the bed might receive a score of one and one-
fourth feet. It was felt that all four dolls could be
comfortably situated next to the side of the bed, above the
marked "one foot" line; any placement beyond this point was
judged as deliberate placement further away from the child.
The stories in the 3D part of the test protocol were
recorded on tape, and later transcribed and scored. No
time limit was set for the child in any portion of the
story telling and, other than the prescribed instructions,
no prompting was given.
In no case was it necessary to break the testing
sessions with the 3D part of the protocol because of the
physical condition of the child, but the entire three-
dimensional replica was administered at one sitting,
immediately after the administration of the four pictures
in the PIX protocol.
69
The scoring system used to score the stories in the
3P part of the protocol was identical to that used in
scoring the PIX part of the protocol. Details are given
in the Appendix.
Hospital-Anxiety (HOSP)
and Home-Anxiety (HOME) '
Following the administration of the first (PIX) and
second (3D) parts of the test protocol, each child was pre
sented with part (c), HOSP and HOME. The 40 questions of
the two-part questionnaire, the State-Trait Anxiety Inven
tory for Children (STAIC) of Spielberger (1970) , were read
to each child, with the examiner circling one of the three
possible answers to each question.
The scale was presented to each child in the follow
ing manner:
Now I'd like to ask you some questions. Would you
like to answer some questions for me? Okay, I have two
sets of questions. First, I'm going to ask you some
questions about how you feel when you're in the hos
pital. Then I'm going to ask you some questions about
how you feel when you're at home. Okay?
The examiner showed each of the two pages to the child,
pointing to the first one as the one to be answered regard
ing the hospital, and to the second page as the one to be
answered regarding home. When the child nodded approval,
the examiner read each of the 20 questions of the HOSP
scale, preceded by the phrase: "When you're in the hospi
tal do you feel . . . ?"
When the examiner had finished reading each of the
70
20 questions of the HOSP scale to the child, circling the
responses, the examiner administered the HOME scale, pre
ceding each question by the phrase: "When you're at home,
do you . . . ?"
The responses were scored on a scale of 0, 1, 2,
with the highest score representing the most anxiety. Pour
children did not complete part (c) of the protocol. De
tails for these four cases are given in the Appendix. The
four cases will be discussed in Chapter V.
Measure of Field Dependence-
Inctependence
After the first three parts of the protocol were
administered, the examiner administered part (d), the Chil
dren's Embedded Figures Test (CEFT), both as an exploratory
measure of personality differences, and to distract the
child from any anxiety that the protocol may have brought
out in the child.
The CEFT section of the protocol was administered
with the instruction: "Now we can play with our puzzle.
Do you like puzzles? Okay, here's what we do." The CEFT
was then presented, with the examiner demonstrating on the
sample figures how the puzzle worked. The child was then
presented with the actual test, according to the instruc
tions as summarized in the Appendix.
The scoring system for the CEFT was as follows.
Each time a child would correctly place the tent-triangle
71
or the house on top of the hidden figure in the larger pic
ture and do so correctly on the first try, the child re
ceived a score of 1^ If he did not place the triangle or
house correctly, or if he did so but not on his first try,
he received a score of £. The best possible score was 25.
The higher the score, the more field independent the child.
With the exception of two children, details of which
will be given in the Appendix and discussed in Chapter V,
all of the remaining children in the study finished this
part of the test protocol immediately after the first three
parts, all in one sitting, in an average time of 20-30
minutes for the entire four parts.
Other Sources of Information
Informal interviews were held both with the nurse
who had most extensive contact with each child in the fa
tally ill group, and with the head nurse or assistant head
nurse for that particular day. The interviews were infor
mal and varied, depending on the nurses* knowledge and ob
servations of the child's behavior and of parent-child in
teraction, and the length of time and the number of times
the child had been hospitalized. The purpose of the inter
view with the nurse was to elicit information on her own
perception of the child's behavior, his overt reaction to
his illness, and the observed quality of the child's inter
action with his parents during hospitalization. As in the
case of Waechter's study (1968), interviews with the nursing
72
personnel varied in amount of elicited information, depend
ing on the length of time since the diagnosis, the number
of times the child had been hospitalized, and the openness
and availability of the parents.
The medical and nursing charts for each hospitalized
child were perused for additional information as to the
current and past behavioral observations and information
relating to the medical circumstances surrounding the
child, the extensiveness of past and current hospitaliza
tions, medications, and other pertinent information entered
into the charts by medical and nursing personnel.
Following the testing of the child, the experimenter
spent some time conversing with the children with fatal
illness, observing their overt behavior, both in their
rooms and in the playroom. The length of time spent with
each child varied according to the length of hospitaliza
tion, and the medical circumstances surrounding the child.
No direct questioning was made of the child; the examiner
tried merely to be friendly and be a companion to the child
while he was playing in his room or in the playroom. Ob
servations were made as to the diagnosis and physical cir
cumstances of other children on the ward as these might
have influenced concerns of the test subjects regarding
body integrity.
Discussion of the observations will be reserved for
Chapter V.
CHAPTER IV
RESULTS
Hypothesis One
The first hypothesis to be tested concerned stories
relating to four pictures: CHILDREN AGED SIX TO TEN YEARS
WITH A FATAL PROGNOSIS WILL RELATE STORIES THAT SHOW A
GREATER PREOCCUPATION WITH THREAT TO THEIR BODY INTEGRITY
AND FUNCTIONING THAN WILL CHILDREN WHO DO NOT HAVE A FATAL
PROGNOSIS. It was predicted that, given a series of four
pictures, the leukemic children in the study would relate
stories that contained more statements portraying an over
all anxiety about the hospital and hospital procedures than
would the non-fatally-ill control children. The means
and standard deviations for the stories relating to the
four pictures (PIX) are summarized in Table 2. An analysis
of variance for the scores was performed, as part of an
overall multivariate analysis of variance, and the results
are summarized in Table 3.
The scores of the first four measures (PIX, 3D,
HOSP, HOME) were covaried for age and grade in school.
The age and grade were shown to have made a significant
73
74
TABLE 2
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR ANXIETY
SCORES ON PROJECTIVE TEST, PICTURES
Leukemic Chronic
First Adm. m = 10.67 m = 2.44
m = 6.56 SD = 6.84 SD = 2.88
Subseq. Adm. m = 10.25 m = 3.81
m = 7.03 SD = 6.17 SD = 3.64
m = 10.40 m = 3.32
overall mean = 6.86
TABLE 3
SUMMARY OF ANALYSIS OF
PROJECTIVE
VARIANCE FOR ANXIETY
TEST, PICTURES
SCORES ON
Source df Mean Squares F
Regression 2 135.49 6.35*
L
(Leuk/non-Leuk)
1 614.83 28.82**
V
(First/Subseq.)
1 7.13 0.33
L X V 1 8.18 0.38
Error 44 21.30
*p < .004
**p < .001
75
difference in the scores (regression analysis overall
p < .021; PIX p < .004; 3D p < .020; HOME p < .002). Age
and grade did not make a significant difference in HOSP
scores.
The first hypothesis, that children aged six to
ten years with a fatal prognosis would relate stories that
show a greater preoccupation with threat to their body
integrity and functioning than would children who do not
have a fatal prognosis, was supported. The resulting F of
28.82 was significant at the .001 level.
Hypothesis Two
The second hypothesis to be tested concerned
stories relating to the placement of figures onto a three-
dimensional hospital-room replica: CHILDREN AGED SIX TO
TEN YEARS WITH A FATAL PROGNOSIS WILL RELATE STORIES OF
PLACED FIGURINES THAT SHOW A GREATER PREOCCUPATION WITH
THREAT TO THEIR BODY INTEGRITY AND FUNCTIONING THAN WILL
CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS. It was pre
dicted that, given a three-dimensional hospital-room
replica with dolls representing meaningful figures in the
child's hospital life, the leukemic children in the study
would relate stories that contained more statements por
traying an overall anxiety about the hospital and hospital
procedures than would the non-fatally-ill control children.
The means and standard deviations for the stories relating
76
to the three-dimensional hospital-room replica (3D) are
summarized in Table 4, An analysis of variance was per
formed on the scores as part of an overall multivariate
analysis of variance, and the results are summarized in
Table 5.
The second hypothesis, that children aged six to
ten years with a fatal prognosis would relate stories of
placed figurines that show a greater preoccupation with
threat to their body integrity and functioning than would
children who do not have a fatal prognosis, was supported.
The resulting F of 32.53 was significant at the .001 level.
Hypothesis Three
The third hypothesis to be tested concerned the
child's anxiety as he himself viewed it in hospital and
hospital-related situations: CHILDREN AGED SIX TO TEN
YEARS WITH A FATAL PROGNOSIS WILL EXPRESS MORE ANXIETY
RELATING TO THE HOSPITAL THAN WILL CHILDREN WHO DO NOT
HAVE A FATAL PROGNOSIS. It was predicted that, given the
State part of the STAIC, and answering the questions in
terms of feelings toward the hospital, the leukemic chil
dren would score higher than the non-fatally-ill control
children. The means and standard deviations for the
STAIC-State or Hospital-Anxiety (HOSP) scores are summa
rized in Table 6. An analysis of variance for the scores
was performed as part of an overall multivariate analysis
77
TABLE 4
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR ANXIETY
SCORES ON PROJECTIVE TEST, THREE-DIMENSIONAL
Leukemic Chronic
First Adm. m
=
9.11 m = 2.00
m = 5.56 SD
=
4.17 SD = 1.94
Subseg. Adm. m
=
8.94 m = 2.44
m = 5.69 SD
=
6.76 SD = 1.41
m 9.00 m = 2.28
overall mean = 5.64
TABLE 5
SUMMARY OF ANALYSIS OF VARIANCE FOR ANXIETY SCORES ON
PROJECTIVE TEST, THREE-DIMENSIONAL
Source df Mean Sguares F
Regression 2 71.70 4.26*
L
(Leuk/non-Leuk)
1 547.37 32.53**
V
(First/Subseg.)
1 1.45 0.09
L X V 1 0.85 0.05
Error 44 16.80
*p < .02
**p < .001
78
of variance, and the results are summarized in Table 7.
The hypothesis that children aged six to ten years
with a fatal prognosis would express more anxiety relating
to the hospital than would children who do not have a
fatal prognosis, was supported. The resulting F of 39.83
was significant at the .001 level.
Hypothesis Four
The fourth hypothesis tested concerned the child's
anxiety in non-hospital-related situations: CHILDREN AGED
SIX TO TEN YEARS WITH A FATAL PROGNOSIS WILL EXPRESS MORE
GENERALIZED ANXIETY RELATING TO NON-HOSPITAL SITUATIONS
THAN WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS. It
was predicted that, given the Trait part of the STAIC, and
answering the questions in terms of feelings when not in
the hospital but when at home, the leukemic children in the
study would score higher than would the non-fatally-ill
control children. The means and standard deviations for
the STAIC-Trait or Home-Anxiety (HOME) scores are summa
rized in Table 8. An analysis of variance was performed
as part of an overall multivariate analysis of variance,
and the results are summarized in Table 9.
The fourth hypothesis, that children aged six to
ten years with a fatal prognosis would express more gener
alized anxiety relating to non-hospital situations than
would children who do not have a fatal prognosis, was
79
TABLE 6
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR SCORES
ON STAIC-STATE, HOSPITAL**ANXIETY
Leukemic Chronic
First Adm. m
=
23.33 m = 8.33
m = 15.83 SD
—
7.91 SD = 5.10
Subseq. Adm. m
=
16.75 m = 9.19
m = 12.97 SD
=
4.52 SD = 4.90
‘ ~nT"= 19.12 m = 8.88
overall mean = 14.00
TABLE 7
SUMMARY OF ANALYSIS OF VARIANCE FOR SCORES ON
STAIC-STATE, HOSPITAL-ANXIETY
Source df Mean Squares F
Regression 2 3.07 0.10
L
(Leuk/non-Leuk)
1 1239.36 39.83*
V
(First/Subseq.)
1 95.85 3.08
L X V 1 160.10 5.15**
Error 44 31.12
*p < .001
**p < .028
80
TABLE 8
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR SCORES
ON STAIC-TRAIT, HOME-ANXIETY
Leukemic Chronic
First Adm. m
=
14.56 m = 9.67
m = 12.11 SD
s
5.10 SD = 5.50
Subseg. Adm. m 15.00 m = 9.56
m = 12.28 SD
=
6.83 SD = 7.7S
m
= 5
14.84 m = 9.60
overall mean = 12.22
TABLE 9
SUMMARY OF ANALYSIS OF VARIANCE FOR SCORES ON
STAIC-TRAIT, HOME-ANXIETY
Source df Mean Squares F
Regression 2 248.60 7.01*
L
(Leuk/non-Leuk)
1 300.36 8.47**
V
(First/Subseq.)
1 3.32 0.09
L X V 1 1.17 0.03
Error 44 35.34
*p < .002
**p < .006
81
supported. The resulting F of 8.47 was significant at the
.006 level.
In addition to evaluating the State and Trait
scores (HOSP and HOME) of the two groups, a further
analysis was performed. Using each child as his own con
trol, each subject's HOME score was subtracted from his
HOSP score, and an analysis of variance was performed on
the resultant scores. The means and standard deviations
for the difference-scores between subjects' State and
Trait scales (HOSP minus HOME) are summarized in Table 10.
The results of the analysis of variance are summarized in
Table 11.
The resultant F of 5.41 was significant at the
.025 level. Thus, not only do the leukemic children score
higher than the non-fatally-ill children both on HOSP and
HOME measures, but using each child as his own control,
the HOSP scores of the leukemic children were significantly
higher than their HOME scores, when compared to the dif
ferences between HOSP and HOME scores for the non-fatally-
ill children.
In addition to the measures reported, a multi
variate analysis of variance was performed on the first
four measures of the protocol taken together as measures of
"hospital-related-anxiety." The resulting overall F of
21.32 between the leukemic and the non-fatally-ill children
for all four measures (PIX, 3D, HOSP, HOME) taken together
82
TABLE 10
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR DIFFERENCE
SCORES BETWEEN HOSPITAL-ANXIETY AND
HOME-ANXIETY, HOSP MINUS HOME
Leukemic Chronic
First Adm. m = 8.33 m = -1.33
m = 3.50 SD = 8.99 SD = 5.52
Subseg. Adm. m = 1.68 m = -0.38
m = 0.66 SD = 6.36 SD = 9.68
m = 4.08
overall mean
m =
= 1.68
-0.72
TABLE 11
SUMMARY OF ANALYSIS OF VARIANCE FOR DIFFERENCE SCORES
BETWEEN HOSPITAL-ANXIETY AND HOME-ANXIETY,
HOSP MINUS HOME
Source df Mean Squares F
Regression 2 238.39 4.32*
L
(Leuk/non-Leuk)
1 298.05 5.41**
V
(First/Subseq.)
1 119.18 2.16
L X V 1 170.93 3.10
Error 44 55.15
*p < .019
**p < .025
83
was significant at the .001 level. Taking all four
measures as a single measure of overall hospital-related-
anxiety, children aged six to ten years with a fatal
prognosis express a significantly higher level of hospital-
related-anxiety than children who do not have a fatal
prognosis.
Hypothesis Five
The fifth hypothesis to be tested was concerned
with the distance from the child in the hospital-room
replica that the subject would place the significant adults
in his hospital life: CHILDREN AGED SIX TO TEN YEARS WITH
A FATAL PROGNOSIS WILL PLACE DOLLS REPRESENTING MEANINGFUL
ADULTS IN THEIR HOSPITAL ENVIRONMENT AT A GREATER DISTANCE
THAN WILL CHILDREN WHO DO NOT HAVE A FATAL PROGNOSIS. It
was predicted that the leukemic children in the study
would place each of the four figures at a greater distance
than would the non-fatally-ill children.
In the initial placement and story telling, the
child was asked to place the figures where they USUALLY are
in the room. At the end of the story telling, the child
was asked to place the figures where he would most LIKE
them to be. We will summarize the results in two parts:
PERSONAL SPACE USUAL and PERSONAL SPACE LIKE.
The measures of personal space, both USUAL and
LIKE, were analyzed without covarying for age and grade.
84
The means and standard deviations for the PERSONAL SPACE
USUAL measures are summarized in Table 12. An analysis of
variance for the scores was performed, and the results are
summarized in Table 13.
The fifth hypothesis, that children aged six to
ten years with a fatal prognosis would place dolls repre
senting meaningful adults in their environment at a greater
distance than would children who do not have a fatal
prognosis, as measured by PERSONAL SPACE USUAL, was sup
ported by an overall analysis of variance taking the four
placements together. The resulting F of 2.70 was signifi
cant at the .043 level.
Taking each figure separately, the fatally ill
children placed the nurse significantly further away
(P = 5.00; p < .030), and they placed the mother signifi
cantly further away (F = 5.23; p < .027). The placements
of the doctor (p < .053) and of the father (p < .075) were
not significant when taken separately.
The distinction between USUAL placement and LIKE
placement was difficult for many of the children to grasp.
Over half of the subjects either did not understand the
distinction or said that their initial placement (USUAL)
was where they would LIKE the figures to be. Analysis of
this fact will be reserved for Chapter V,
The means and standard deviations for the PERSONAL
I
SPACE LIKE measures are summarized in Table 14. An
85
TABLE 12
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR
MEASURES OF PERSONAL SPACE USUAL
-
Leukemic Chronic
The Nurse
First Adm. m = 1.31 m = 1.20
m = 1.25 SD = 1.09 SD = 0.50
Subseg. Adm. m = 3.27 m = 1.75
m — 2.51 SD = 2.39 SD = 1.16
m » 2.56 m = 1.55
overall mean = 2.06
The Doctor
First Adm. m = 0.89 m = 0.86
m = 0.88 SD * 0.57 SD = 0.60
Subseg. Adm. m = 2.96 m = 1.63
m = 2.30 SD = 2.23 SD = 1.39
m = 2.22 m = 1.35
overall mean = * 1.79
The Mother
First Adm. m = 1.75 m = 1.28
m « 1.51 SD = 1.22 SD = 1.21
Subseg. Adm. m = 3.29 m = 1.82
m = 2.56 SD = 2.58 SD = 0.97
m = 2.74 m = 1.62
overall mean = 2.18
TABLE 12— Continued
86
Leukemic Chronic
The Father
First Adm. m = 1.53 m = 1.89
m = 1.71 SD = 1.13 SD = 2.01
Subseq. Adm. m = 3.14 m = 1.63
m = 2.38 SD = 2.07 SD = 0.99
m = 2.56 m — 1.72
overall mean = 2.14
87
TABLE 13
SUMMARY OF ANALYSIS OF VARIANCE FOR MEASURES
OF PERSONAL SPACE USUAL
Source df Mean Squares F
The Nurse
L
(Leuk/non-Leuk)
1 12.75 5.00*
V
(First/Subseq.)
1 18.28 7.17**
L X V 1 5.75 2.26
Error 46 2.55
*p < .030
**p < .010
The Doctor
L
(Leuk/non-Leuk)
1 9.33 3.93
V
(First/Subseq.)
1 23.34 9.84*
L X V 1 4.92 2.07
Error 46 2.37
*p < .003
TABLE 13— Continued
88
Source df Mean Squares F
The Mother
L
(Leuk/non-Leuk)
1 15.57 5.23*
V
(First/Subseq.)
1 12.48 4.19**
L X V 1 2.91 0.98
Error 46 2.98
*p < .027
**p < .046
The Father
L
(Leuk/non-Leuk)
1 8.78 3.32
V
(First/Subseq.)
1 5.22 1.97
L X V 1 10.11 3.82
Error 46 2.64
TABLE 14
SUMMARY OF MEANS AND STANDARD DEVIATIONS
MEASURES OF PERSONAL SPACE LIKE
89
FOR
Leukemic Chronic
The Nurse
First Adm. m = 2.53 m = 2.23
m = 2.37 SD = 2.09 SD = 2.95
Subseg. Adm. m = 3.37 m = 1.81
m = 2.58 SD = 2.50 SD - 2.43
m — 3.06 m = 1.96
overall mean = 2.51
The Doctor
First Adm. m = 2.44 m = 2.28
m = 2.36 SD = 3.22 SD = 3.19
Subseg. Adm. m = 3,23 m = 2.09
m = 2.66 SD = 3.10 SD = 2.52
m « 2.95 m = = 2.16
overall mean = 2.55
The Mother
First Adm. m = 1.75 m = 0,81
m = 1.28 SD = 1.22 SD = 0.54
Subseg. Adm. m = 3.08 m = 1.64
m = 2.36 SD » 2.77 SD = 1.77
m = 2.60 m = 1.34
overall mean = 1.97
TABLE 14— Continued
90
Leukemic Chronic
The Father
First Adm. m = 1.22 m = 0.75
m = 0.98 SD = 1.05 SD = 0.52
Subseg. Adm. m = 2.92 m = 0.95
m = 1.94 SD = 2.49 SD = 0.70
m = 2.31 m « 0.88
overall mean = 1.59
91
analysis of variance was performed, and the results are
summarized in Table 15.
In an analysis of variance taking the four place-
ments in PERSONAL SPACE LIKE together, the F of 3.28 was
significant at the .020 level. Thus the fifth hypothesis,
that children aged six to ten years with a fatal prognosis
would place dolls representing meaningful adults in their
environment at a greater distance than would children who
do not have a fatal prognosis, as measured by PERSONAL
SPACE LIKE, was supported by an analysis taking the four
placements together.
Taking each of the placements of PERSONAL SPACE
LIKE separately, the two significant placements that con
tributed the most to the overall effect were those of the
mother (F = 5.15; p < .028) and of the father (F = 10.55;
p < .002). The placements of the nurse (p < .125) and of
the doctor (p < .35) for PERSONAL SPACE LIKE were not
significant when taken separately.
Hypothesis Six
The sixth hypothesis to be tested concerned the
differences in all of the measures in the test protocol
between children in their first visit to the hospital and
children in subsequent admission: PREOCCUPATION WITH
THREAT TO BODY INTEGRITY AND FUNCTIONING, HOSPITAL-RELATED
AND NON-HOSPITAL-RELATED ANXIETY, AND PERSONAL SPACE
92
TABLE 15
SUMMARY OP ANALYSIS OF VARIANCE FOR MEASURES
OF PERSONAL SPACE LIKE
Source df Mean Squares F
L
The Nurse
1 15.19 2.44
(Leuk/non-Leuk)
V 1 0.52 0.08
(First/Subseq.)
L X V 1 4.51 0.73
Error 46 6.23
The Doctor
L
(Leuk/non-Leuk)
1 7.76 0.87
V
(First/Subseq.)
1 1.05 0.12
L X V 1 2.71 0.31
Error 46 8.76
The Mother
L
(Leuk/non-Leuk)
1 19.77 5.15*
V
(First/Subseq.)
1 13.45 3.51
L X V 1 0.69 0.18
Error 46 3.83
*p < .028
TABLE 15— Continued
93
Source df Mean Squares F
The Father
1 25.46 10.55*
1 10.41 4.31**
1 6.41 2.66
46 2.41
*p < .002
**p < .043
L
(Leuk/non-Leuk)
V
(First/Subseq.)
L X V
Error
94
MEASURES WILL BE GREATER FOR CHILDREN IN SUBSEQUENT VISITS
TO THE HOSPITAL THAN FOR THOSE WHO ARE VISITING THE HOS
PITAL FOR THE FIRST TIME FOR THE ADMITTING ILLNESS. It
was predicted that, in all of the measures, the general
anxiety related to the hospital would be greater for chil
dren in subsequent admissions to the hospital than for
those in their first visit to the hospital for the
admitting illness.
The means, standard deviations, and results of the
analyses of variance for the scores are summarized in the
foregoing Tables 2-15, pages 74-96.
There were no significant differences between first
and subsequent admissions in PIX, 3D, HOSP or HOME scores.
There was a significant interaction in the HOSP measure.
Table 7, page 79 (F = 5.15; p < .028). This result will be
discussed in Chapter V.
In the PERSONAL SPACE USUAL measure, there was a
significant difference between the placements of the
children in first admission and those in subsequent
admission to the hospital. As can be seen in Table 13
(page 87), the sixth hypothesis is supported in part by
the PERSONAL SPACE USUAL measures. The resulting F of 3.80
for the four PERSONAL SPACE USUAL placements taken together
was significant at the .010 level. There was a significant
difference between the first and subsequent admissions in
the placement of the figurines, with the subsequent
95
admissions placing the figurines further away than the
first admissions.
Taking each figure separately, the children in
subsequent admissions to the hospital placed the nurse
significantly further away (F = 7,17; p < ,010); they
placed the doctor significantly further away (F = 9.84;
p < ,003); and they placed the mother significantly further
away (F = 4.19; p < .046). The placement of the father
was not significant for PERSONAL SPACE USUAL, comparing
first to subsequent admissions.
The measures for PERSONAL SPACE LIKE (Table 15)
proved r.on-significant for the four figures taken as a
whole. Taking each figure separately, the only significant
placement was that of the father (F = 4,31; p < .043).
Analysis of this datum will be reserved for Chapter V.
In brief, the sixth hypothesis was not supported
by the PIX, 3D, HOSP or HOME measures. It was supported in
part by the personal space measures. Children in subse
quent admissions to the hospital did not express greater
preoccupation with threat to body integrity or functioning,
nor greater hospital-related or non-hospital-related
anxiety than did children in their first admission. How
ever, children in subsequent admissions to the hospital did
place significant adult figures in their hospital environ
ment at a greater distance than did the children who were
visiting the hospital for the first time for the admitting
96
illness.
Hypothesis Seven
The seventh hypothesis was concerned with relation
ships between anxiety measures and measures of field
dependence-independence in the fatally ill children:
CHILDREN AGED SIX TO TEN YEARS WITH A FATAL PROGNOSIS WHO
SCORE HIGHEST IN THE VARIOUS MEASURES OF ANXIETY (PIX, 3D,
HOSP, HOME) WILL ALSO SCORE HIGHEST ON MEASURES OF FIELD
INDEPENDENCE. It was predicted that the leukemic children
who were the most field independent would be the most
capable of observing any alteration in the emotional
climate around them, or would more readily "see through"
the well-intentioned attempts of adults to hide the
diagnosis from them. As a result, the field independent
leukemic children would be expected to "pick up" more cues
of anxiety from those around them than would the field
dependent.
The correlations between field independence scores
(CEFT) and the various anxiety measures (PIX, 3D, HOSP,
HOME) are summarized in Table 16. As can be seen from the
table, the correlations are relatively poor. The seventh
hypothesis, that children aged six to ten years with a
fatal prognosis who score highest in the various measures
of anxiety would also score highest on the measure of
field independence, is not supported by the data.
I
97
TABLE 16
CORRELATIONS BETWEEN MEASURES OF ANXIETY AND THE
MEASURE OF FIELD INDEPENDENCE FOR THE
LEUKEMIC CHILDREN IN THE STUDY
CEFT and PIX = .30
CEFT and 3D = .30
CEFT and HOSP = .09
CEFT and HOME = .32
(n = 25)
98
In addition to the foregoing correlation, a further
analysis of the data was performed. If, in fact, leukemic
children scored higher on the measures of anxiety, it would
be of interest to compare their measures on field inde
pendence with those of the non-fatally-ill control group,
as a further test of whether field independents are highly
anxious, and vice versa.
An analysis of variance was performed on the CEFT
scores of the children in the study. The means and
standard deviations for the scores are summarized in
Table 17. The results of the analysis of variance are
summarized in Table 18.
With the CEFT scores covaried for age and grade,
the resulting F of 5.25 between the leukemic and the
chronically ill groups of children is significant at the
.045 level.
The leukemic children were significantly more
field independent than the control population. Discussion
of this finding will be reserved for Chapter V.
99
TABLE 17
SUMMARY OP MEANS AND STANDARD DEVIATIONS FOR NUMBER
CORRECT IN THE MEASURE OF FIELD INDEPENDENCE
Leukemic Chronic
First Adm. m = 19.44 m = 16.22
m = 17.83 SD = 4.28 SD = 6.69
Subseg. Adm. m = 17.63 m = 15.75
m = 16.68 SD = 6.33 SD = 5.88
m = 18.28 m = 15.72
overall mean = 17.10
TABLE 18
SUMMARY OF ANALYSIS OF VARIANCE FOR THE NUMBER CORRECT
IN THE MEASURE OF FIELD INDEPENDENCE
Source df Mean Squares F
Regression 2 420.65 23.63*
L
(Leuk/non-Leuk)
1 75.62 4.25**
V
(First/Subseq.)
1 3.97 0.22
L X V 1 3.91 0.22
Error 44 17.80
*p < .001
**p < .045
I
CHAPTER V
DISCUSSION
Despite efforts to shield children with fatal
illness from awareness of their prognosis, it has been
claimed that the anxiety of meaningful adults is conveyed
to the children through the altered emotional climate
around them. The present study attempted to explore the
truth of this statement.
How much does a child with a fatal illness know
about his illness, even when no one has told him that his
illness is serious? Does a child aged six to ten years
with a diagnosis of leukemia have any suspicion about the
fatality or seriousness of his illness? These are the
questions that, the present study attempted to answer using
non-obtrusive measures.
The study was initiated with a two-part review of
the literature. First, a survey was made on the attitudes
of normal children toward death. It was found that normal
children do not come to an adult-like grasp of the concept
of death until about the age of eleven. From the ages of
six to about ten, the child is in a stage during which he
100
I
101
has some appreciation of the facts of death, but has not
yet come to a full understanding of the concept. It was
this latter age group, from six to about ten, that formed
the main interest of the study.
How do the attitudes of normal children toward
death compare with the attitudes of fatally ill children
toward death? Are they the same? Or do fatally ill chil
dren come to an earlier awareness of the meaning of death?
Does the fatally ill child have an understanding of death
and what it implies at an age younger than the normal
child?
These questions led to the second part of the
review of the literature: a survey of the attitudes of
fatally ill children toward their own illness. All but
one of the authors writing about fatally ill children felt
that for the fatally ill child under five, fears of
separation are paramount. For the child from six to about
ten, fears relating to physical injury, intrusion into
body integrity and mutilation are foremost. After ten,
expressed fears of impending death become more pronounced.
These studies found that the attitudes toward and awareness
of death in the fatally ill child progress along the same
general developmental stages as do the attitudes toward
death in the normal child. In the years from six to about
ten, the manifestations of death fear are vague and
evanescent, and expressed anxiety is generally related to
102
intrusive or painful operating procedures.
The one study that disagreed in part with the
majority of authors in this area was that of Waechter
(1968). It was Waechter's contention and finding that,
contrary to the findings of earlier authors, expressed
death anxiety is present in children aged six to ten.
Waechter found a higher degree both of overtly expressed
death themes and of separation themes than of mutilation
themes among the fatally ill children in her study.
The problem presenting itself at the beginning of
the present study was this seeming conflict. All of the
previous studies had pointed in the same direction:
children aged six to ten years were not yet old enough to
grasp the full meaning of the concept of death, and
fatally ill children in this age group were more overtly
concerned with intrusion into their body integrity and
functioning than they were with death. Waechter's findings
contradict the findings of the previous authors.
It was the contention of the present investigator
that reliance on overt expressions of death anxiety may
give an incomplete or distorted picture of the actual con
cerns of the fatally ill child. A child may not yet grasp
the concept of death in an adult fashion but may, neverthe
less, have very real concerns about his fatal condition
which may cause him great anxiety. If medical and nursing
personnel working with fatally ill children in the age
103
group six to ten were to look for overt expressions of
death, in accord with Waechter's findings, they might over
look the very real concerns related to the fatal illness
which may not be overt concerns about death.
Reliance on overt expressions about death from a
child too young to fully comprehend death may give the
already wary professional or parent sufficient excuse to
say that the child does not speak of death, and therefore
has no worries or fears. It was the purpose of the present
study to demonstrate that the child who is fatally ill is
concerned about his illness, and that, even though this
concern did not take the form of overt expressions about
death, the more subtle fears emanating from his illness
are nevertheless real and painful.
It was the purpose of the study to show that,
despite efforts to shield children with a fatal illness
from awareness of their prognosis, the anxiety of meaning
ful adults is conveyed to the children through the altered
emotional climate around them, in very subtle but very real
ways.
The results of the study are incontrovertible.
Although the term "death" was only used once in the study
and by a non-fatally-ill child, nevertheless the fatally
ill children did show significant differences in awareness
of their hospital experience, compared to the chronically
ill children in the control groups. Discussion of the
104
results follows.
Measures of Anxiety Relating
to the HospitaT
The leukemic children related significantly more
stories (p < .001) that contained elements of preoccupation
with threat to their body integrity and functioning than
did the chronically ill children, both on the pictures
(PIX) and in the stories told about the placed figurines
(3D) (Tables 3 and 5, pages 74 and 77). Gross and overt
references to the concept of death were virtually non
existent, and separation themes were only minimally pres
ent. But the children with fatal illness did show a
subtle awareness of intrusion into their own body integrity
and functioning, and expressed more hospital-related and
non-hospital-related anxiety than did the chronically ill
children. The fatally ill children in the study were very
preoccupied with concerns of mutilation or threat to their
body integrity and functioning.
During the nine-month course of the study, observa
tions were made as to the diagnosis and physical circum
stances of other children on the ward as these might have
influenced the concerns of the test subjects regarding
body integrity. Two not atypical cases will be summarized
in some detail.
CASE A; Case A was a five and one-half year old
girl who had been hospitalized several times previously for
105
treatment of leukemia. She had always been outgoing,
talkative, and friendly to nursing and medical personnel.
About one week into her eighth hospitalization, several
events took place. During the course of a four-day period,
the ward experienced two deaths and one near-death. In
the case of the first death, the subject was a roommate of
the child who died. The child had become very ill during
the middle of the night while the subject was asleep. The
staff moved the sleeping subject to another room, and pro
ceeded with the necessary emergency procedures in a futile
attempt to save the life of the roommate. The roommate
died during the night. The next morning, the subject
awakened in another room, asked why she was moved and
where her friend was. Responses were that her friend had
gone home.
Two days later, in the middle of the day, another
emergency occurred. The staff came running down the hall
with the emergency equipment, went into a room, pulled the
curtain and closed the door. The subject asked what had
happened. Answers were not to her satisfaction. The
subject began to withdraw into herself. By the time a
third emergency occurred the next evening, the subject had
stopped talking. She would not speak to her mother, the
nurses, doctors or other visitors who came to see her.
The change of mood was sudden and obvious. For a
period of six weeks, this once lively and jovial girl did
106
not speak and did not smile. All attempts were made by a
very understanding medical and nursing staff to bring her
out of her depressed mood. Her mother took a leave of
absence from work in order to be able to be with her
daughter constantly. By the end of the six week period,
the girl was beginning to show signs of physical improve
ment, but was not yet responding in words or smiles. She
had all of the overt signs of a serious depression.
When her physical condition became somewhat
improved at the end of the six week period, the medical
staff decided to allow her to go home, in the hope that
the familiarity of her home surroundings would help draw
her out of her depression.
When the girl was readmitted to the hospital about
two weeks later, her disposition had improved only a
little. She was smiling, but her words were few and
studied. She was no longer the lively little girl she had
been. It was during this admission that the examiner
administered the test protocol to the girl. She expressed
willingness and eagerness to come to the room with the
examiner to "play the games” with him. She was brought to
the testing room in a wheelchair and with an IV in her arm.
During the presentation of the PIX protocol, the
girl answered all questions with the statement: "I don't
know," and with her head bowed and her expression somber.
When asked if she wished to return to her room, she
I
107
indicated that she wanted to continue playing. During the
presentation of the 3D protocol, the girl described what
was in the room, but would make no further positive state
ments. Although she did place the dolls as instructed, she
responded to all questions with the statement: "I don't
know."
Again, she was asked if she preferred to return to
her room, but she indicated her desire to continue. When
she was presented with the HOSP and HOME protocols, she
answered by nodding her head at the response she wished to
choose.
At the end of the HOSP and HOME protocols, the sub
ject expressed a wish to continue playing the "game," so
the examiner presented her with the CEFT protocol. The
girl was noticeably more relaxed during this part of the
"game," but she tired quickly, and asked to leave and go
to the playroom.
The next morning, when the examiner arrived on the
ward, the girl was in the playroom. When she noticed the
examiner, she indicated that she wanted him to come and
play with her. She sat on his lap in the playroom for
about two hours, reading stories, painting, and playing
with games. In contrast to her responses of "I don't know"
on the previous day, she was now talkative and playful,
though still somber.
I
108
The girl's mother indicated that, during the pre
vious admission, when the three emergencies occurred on
the floor, the girl had asked her mother: "Mommy, am I
going to die?" The mother had responded: "No, dear.
You're not going to die." No further conversation was had
about the matter.
It seems that this subject's "I don't know"
responses to the PIX and 3D story telling were indicative
of her unwillingness to share with the examiner her under
standing of what was happening to her.
A similar case occurred about the same time.
CASE B: Case B was a fatally ill six and one-half
year old girl with Wilm's Tumor who, although not involved
in the study, was nevertheless followed closely while on
the ward.
About six months prior to the hospitalization in
question, just after the child's illness had been diag
nosed, the mother and daughter were shopping in a store in
their home neighborhood. The mother relates that a
neighbor's child approached her daughter and told her that
she would die within two years. When the girl later asked
her mother if she were going to die, the mother responded:
"We all have to die sometime, some sooner, some later. We
all must die. But we never know when."
At the beginning of the hospitalization in ques
tion, the mother introduced her daughter to a next-door
I
109
roommate, a four-year-old girl with the identical illness
who had had the disease for a two-year period. The subject
became very attached to her new-found friend and, according
to the mother, found solace in the fact that her friend
had the identical illness and still looked so healthy after
so long a bout with the illness.
During the four day period referred to earlier
when the two deaths and one near-death occurred on the
ward, one of the deaths that occurred was that of the
subject's new-found friend. The subject heard the emer
gency procedures that were going on in the next room, and,
when it was all over, asked her mother what had happened
to her friend. Her mother responded that her friend was
very sick and had to be taken to a room upstairs where
they could take better care of her.
The mother later reported that she herself had
become very upset by the death and was not able to hide
her feelings. She felt that her daughter picked up her
feelings and sensed the seriousness of what had happened.
Her daughter was visibly shaken by the event. Although not
usually talkative, the girl became more noticeably with
drawn and depressed. The nursing personnel were very good
to the girl. They went out of their way to drop in and
say hello as often as they could. They tried to console
her with conversation and stories and games. When the
girl's depression continued, the nursing and medical staff
110
felt it might do the subject some good if she were given
a talkative and happy roommate. Accordingly, when a newly
diagnosed leukemic girl aged eight years was admitted to
the hospital, she was placed into the same room as the
subject. The girls became fast friends, and the subject
seemed to be cheered by her new roommate.
During the course of the second night with her new
roommate, the subject was having difficulty falling asleep.
Her own mother had gone home for the first time in the
three-week period of the present hospitalization. The
mother of the roommate approached the subject to try to
console her. Overly distraught herself at the newly dis
covered diagnosis of her own daughter, the mother spoke too
freely and openly with the subject about the future course
of her illness, without the subject's own mother present
to help console her. The subject was very disturbed by
the conversation, and was upset when her own mother
returned the following morning.
In the meantime, the roommate's mother, who had
been very upset about her own daughter's fatal prognosis,
refused to allow her daughter to be treated for leukemia,
and removed her from the hospital.
The subject became more and more depressed. When
her physical condition improved about two weeks later, she
was released from the hospital and allowed to go home, in
the hope that the familiar surroundings would help her out
of her depression.
When the subject was re-admitted to the hospital
about one week later, she was still very quiet and de
pressed. She had heard about the "games" the examiner was
playing, and expressed an interest in playing them. She
responded to the test protocol with stories that were
brief but filled with anxiety and preoccupation with threat
to her body integrity and functioning. Although she did
not refer to death, she was visibly anxious about the
seriousness of her illness.
Both Case A and Case B illustrate the point of the
study. Although neither girl spoke about death during the
course of the testing sessions, and did not speak about
death to anyone on the staff, the girls were both very
concerned about the seriousness of their illness.
Similar anecdotal observations were made about
others of the leukemic children. Typical of leukemic
children were statements overheard on many occasions such
as: "Why did you tell him, mom?" or "Don't tell him, dad."
The former statement was first overheard when the examiner
went into the room of a six and one-half year old leukemic
boy who had been hospitalized several times for treatment
of his illness. When the examiner first entered the room
and introduced himself, the mother began to explain how
poorly the boy felt that morning. The boy interjected:
"Don't tell him, mom." The mother later explained that the
112
boy did not want her to tell anyone on the medical or
nursing staff if he felt ill, because he did not like the
procedures used to treat his illness.
On a second occasion, the examiner had spoken to
the parents of a newly diagnosed leukemic boy and had
obtained permission to include the six year old first
grader in the study. When the examiner entered the room
where the boy was lying in bed and approached the bed, the
boy turned in the opposite direction. He had undergone two
days of intensive testing and medical examinations and
wanted nothing more to do with anyone on the hospital
staff. The boy did not respond to any conversational ques
tions posed by the examiner, even though the mother and
father both tried to let the boy know that the examiner
was not a medical doctor and would not physically examine
the boy. When the examiner asked how the boy was feeling,
and the father began to answer, the boy interrupted:
"Don't tell him, dad."
These two responses are typical of those reported
by other parents of leukemic children as the general atti
tudes of their children toward medical and nursing person
nel. Responses to questions dealing with the hospital or
personal illness are kept at a very non-trusting level.
The child will often respond that he feels all right, that
all is "okay," even though he may be suffering physical
pain.
113
Given this attitude on the part of the fatally ill
child of avoiding any further pain by keeping to himself
true feelings about his physical condition when approached
by medical and nursing staff, it would seem that responses
to the STAIC-State or HOSP questionnaire would follow the
same resisting pattern, and that some children would not
respond truthfully to the questions. There were many
leukemic children in Cell C (subsequent admissions) who had
related anxiety-filled stories in both the PIX and 3D sec
tions of the protocol and who appeared tense and not a
little unsteady when approached with the questionnaire
about the hospital. For example, in response to the
question: "When you're in the hospital, do you feel very
calm, calm, or not calm?" many children in Cell C (leuke
mic, subsequent admission) would take 10-15 seconds to
answer, appear tense, and finally, in a shaking voice,
respond: "Calm." The same manner of responding would con
tinue throughout the questionnaire on HOSP, whereas, when
the questions on HOME were asked, there was a noticeable
change of affect in the same children toward a more relaxed
posture and voice, and a quicker response.
It would seem that the responses to HOSP as given
by the children in Cell C and as recorded and analyzed in
the final data analysis (Tables 6 and 7, page 79) were on
the conservative side; that is, the responses did not
reflect the true level of anxiety but a lesser level, in
114
the child's attempt to "fool" the examiner.
Three points should be made in light of this
interpretation. First of all, had the children responded
with answers that reflected their true feelings, both as
observed during the actual testing and as interpreted by
parents and medical and nursing personnel about the child's
general reactions to them and to the hospital, the scores
for Cell C for HOSP measures would have been much greater.
This would have been in keeping with the scores for Cell C
in the remainder of the measures in the test protocol.
Secondly, the overall multivariate analysis of
variance did not yield a significant interaction measure,
and thus the HOSP interaction could well be attributed to
chance factors alone.
Finally, given the conservative nature of the
responses, the data nevertheless proved significant at the
.001 level. Truly representative responses would have
provided an even larger F score.
In light of other observations and in comparison
with the remaining data, it is felt that the significance
in interaction measures for the HOSP score (Table 7, page
79) should be discounted and that, in fact, the HOSP
measures for Cell C are greater than those recorded.
During the course of the study, several other
observations lend credence to the foregoing interpretation
of the data. The non-fatally-ill children would inevitably
115
stop the examiner in the hall of the ward the day following
the testing session and would ask if they could come in
and play the games again. They were noticeably happy to
see the examiner, and liked the "games."
This was not true for the fatally ill children.
Only one leukemic child asked to play again. Most of the
children in the fatally ill group were happy to see the
examiner and would respond with a smile, but made no
references to the "games," except for the following occa
sions.
During the testing sessions, there were four chil
dren who did not finish the entire protocol. Although all
of the children in the study finished the PIX and 3D parts
of the test, subjects C5, C8, C12 and C14 did not finish.
Subject C5 said that he was too tired to play any more
after he had finished the story telling related to the
three-dimensional replica. He wanted to return to his
room. Later that day, he smiled and spoke to the examiner
but, without prompting, refused to go back to the room and
finish playing the games.
Subject C8 also asked to leave the room at the
completion of the story telling related to the three-
dimensional replica. When approached later in the same day
and again the following morning, the subject responded to
the examiner with a smile and with some conversation. But
on both occasions, spontaneously and without prompting, the
116
boy turned to his mother and said: "I'm not going to play
any more of those games with him."
Both boys were disturbed by the projective story
telling parts of the protocol.
Subject C12 finished parts PIX and 3D of the proto
col and was a little disturbed by the HOSP part of the
test. He refused to take the HOME part of the protocol but
wanted to play with the puzzle. After the administration
of the CEFT, the examiner asked if the subject wished to
take the HOME part of the test. He refused.
Subject C14 remained virtually silent throughout
the presentation of PIX and 3D except for a few scattered
"I don't know" statements. Since this subject appeared
very tense and apprehensive during the presentation of the
three-dimensional part of the protocol, the test was
stopped and the subject returned to his room. The examiner
spent quite a bit of time with the subject in his room
playing non-test-related games until the subject was calm
and back to his normal composure. Later in the same day,
the examiner went back to the subj ect's room to play the
CEFT "game" with him. The subject responded happily to
this puzzle. The items HOSP and HOME were not attempted.
In contrast to the chronically ill children, many
of whom wanted to play the games again, and most of whom
seemed visibly pleased with having played the games, the
leukemic children were less positively responsive to the
experience.
Finally, in contrast to the chronically ill chil
dren, all of whom played the games when asked, three
leukemic children did not want to play at all, and so were
not included in the study. Case 1 was a five and one-half
year old girl with leukemia who had been in the hospital
several times for treatment of her illness. The examiner
obtained permission from the girl's grandmother-guardian
for her inclusion in the study. When the examiner ap
proached the girl, she feigned sleep, and would not
respond. The examiner went to see the girl daily for the
four-week period of her hospitalization, with the same
response from the girl. She was always too tired or too
sleepy to come and "play the games" with the examiner. By
the end of the four week period, the girl was responding
to the examiner with a yes or no nod and with one word
responses to conversational questions and seemed happy to
see him. At the end of the four week period, the girl
went home from the hospital. She returned a week later,
and continued to respond to the examiner with a smile and
with one word answers, but refused to play the games even
though she was able to move freely about the floor and go
to the cafeteria in a wheelchair. The examiner continued
seeing her daily and trying to become a friend and com
panion but, at her obvious desire, did not try to pursue
interest in having her participate in the study.
118
Case 2 was that of a newly diagnosed six year old
first grader. After obtaining permission from the boy's
parents for his inclusion in the study, the examiner
approached the boy. He refused to come and play any games.
He was very nervous about being in the hospital. The
parents, when they saw this reaction, asked that the
examiner come back the following morning to play the games.
When the examiner arrived back the following morning, the
parents had left the ward to take the boy home, and had
done so without the permission of the head nurse and
without signing the proper papers. The parents were
reported as having been noticeably disturbed over the
diagnosis and over their son's reactions to his first
hospital experience. They wanted to have their son leave
the hospital as quickly as possible.
Case 3 was a similar case, a newly diagnosed seven
year old boy. As in Case 2, the parents readily gave per
mission for inclusion of their son in the study, but each
time the examiner approached the room, the boy was too
tired to take the test. By the third day, the boy was
released from the hospital and allowed to go home.
In all three of the cases, it became clear from
the reactions both of the children and of the parents that
the hospital was a very frightening place for the child,
especially when the parents were noticeably upset by the
diagnosis.
119
It seems, in brief, that the test protocol was a
conservative measure of the true feelings of the children
and that, in fact, responses truly indicative of the chil
dren's feelings would have resulted in even greater anxiety
scores. Nevertheless, the leukemic children related
stories of preoccupation with threat to their body integ
rity at a level significantly higher (.001) than the
chronically ill children (Tables 3 and 5, pages 74 and 77).
The leukemic children scored significantly higher (.001) in
what we have termed hospital anxiety than did the chroni
cally ill children (Table 7, page 79). And the fatally ill
group scored significantly higher (.006) than the control
group in what we have termed home anxiety (Table 9, page
80).
Taking all four major measures together (PIX, 3D,
HOSP, HOME) as an overall measure of hospital-related
anxiety, the leukemic children scored as significantly more
anxious (p < .001) about hospitals and hospital-related
procedures than did the chronically ill children.
If, as the parents of the twenty-five leukemic
children maintained, their child did not know that his
illness was fatal, and if the chronically ill children
received the same number and duration of hospital-related
treatments, there should have been no difference between
the scores of the fatally ill children and the scores of
the chronically ill children. Yet, the fatally ill
I
120
children showed a greater overall anxiety and a greater
preoccupation with threat to their body integrity and
functioning than did the chronically ill. It seems that,
despite efforts to shield the child with a fatal illness
from awareness of his prognosis, he somehow picks up a
sense of his illness as being more serious and more
threatening.
Measures of Personal Space
Observations of medical and nursing personnel and
of parents indicate that they do not stay physically
further away from the fatally ill child when they enter
the room than they do when they attend the non-fatally-ill
children. But conversation with the staff leads one to
conclude that the frequency of contact with the fatally ill
child by the staff is reduced, and that the type of con
tact by both parents and staff is greatly altered.
In the study, the distance of placement of meaning
ful adult figures by leukemic children was significantly
larger than the placement by the chronically ill children
(Tables 12 and 13, pages 85 and 87). The distance of
placement of meaningful adults by the children in subse
quent admissions to the hospital was significantly larger
than the placement by children in their first admission.
Though no apparent physical difference is present in the
actual bed care stance of medical and nursing personnel,
121
the fatally ill child in subsequent admissions to the
hospital placed the meaningful figures in his hospital
environment further away than did the other cells in the
study.
Although both leukemic and chronically ill children
placed doctors and nurses further away in the LIKE place
ment, compared to their USUAL placement, and although both
leukemic and chronically ill children placed mothers and
fathers closer in LIKE placement, compared to their USUAL
placement (Tables 14 and 15, pages 89 and 92), over half of
the children in the study did not comprehend the distinc
tion between USUAL and LIKE placements. Given this fact,
it would seem inappropriate to draw any conclusions from
the data based on the distinction.
The only datum that was surprisingly different
than expected was the lack of significant difference in the
placement of the father in the PERSONAL SPACE USUAL
measure, compared to the significance in the placement of
the father in the PERSONAL SPACE LIKE measure. Those who
responded to the PERSONAL SPACE LIKE measure indicated that
they would like the father much closer than he actually
was. Given both the lack of paternal presence for most of
the working day for both leukemic and non-leukemic children
in the hospital, and given the role of the father in the
life of the normal six to ten year old child, compared to
the mother's role, perhaps the results reflect more the
122
reactions to fathers generally among six to ten year olds
than they reflect anything peculiar to hospitalized
children. Further study needs to be done on this datum.
How does one interpret the overall finding in the
personal space measure, of the significant differences in
the placements of the adult figures?
Given both the personal space placements and the
results of the four anxiety measures, it would seem appro
priate to infer that the placements, not reflective of
actual physical distance, are actually a reflection of a
growing separation of the child's feelings from the adults
in his environment, a mirroring of the altered emotional
climate in the adults around him.
It is the contention of the present investigator
that the placement of the figures does in fact reflect a
psychological distance felt by the child both in regard to
his own feelings and in the reflected awareness of the
psychological distance of the parents and of the medical
and nursing personnel.
Measure of Field Independence
It was the hypothesis of the study that those
fatally ill children who were the most field independent
would be the most capable of sorting out subtle cues in
their environment and hence would "pick up" the most
anxiety from the adults around them. The correlations
123
between anxiety scores and measures of field independence
did not support this hypothesis.
One finding of interest was the significant dif
ference between field dependent and field independent
measures comparing the leukemic to the chronically ill
children. Given an initial random selection of children
for inclusion into the study, it would seem that field
dependence-independence should be evenly distributed
between the two groups. However, an analysis of variance
performed on the scores (Table 18, page 99) showed that the
leukemic children in the study were significantly more
field independent than the chronically ill children.
Since the correlation between anxiety measures and
scores on field dependence-independence (Table 16, page
97) were not high enough to allow for any reasonable con
clusion in favor of a relationship, it is difficult to
draw a solid inference from the fact that the leukemic
children in the study sample were significantly more field
independent than the control group.
The CEFT was a valuable tool for distracting the
child from any anxiety that may have arisen from the test
protocol itself. As a measure of personality differences
that might prove useful in differentiating anxiety-
proneness in the fatally ill child, the concept of field
dependence-independence remains in an exploratory state.
Certainly, further testing is necessary before one will be
enabled to draw favorable conclusions.
124
Conclusions
The two general results are clear. The fatally
ill child responds to projective story telling with a
greater preoccupation with threat to his body integrity
and functioning and responds to questionnaires with a
higher degree of anxiety about hospital-related and non
hospital-related situations than does the non-fatally-ill
hospitalized child. Secondly/ the fatally ill child in
subsequent admissions to the hospital places dolls repre
senting significant figures in his hospital environment at
a greater distance than does his chronically ill companion.
It is clear that the fatally ill six to ten year
old child is concerned about his illness and that, even
though this concern did not take the form of overt expres
sions about death, the more subtle fears are nevertheless
real, painful, and very much related to the seriousness of
the illness the child is experiencing.
It is felt that a tendency for adults in the
child's hospital environment, both parents and medical and
nursing personnel, to cope with their own anxieties by
avoiding the child and his questions when he needs their
support the most will leave the child increasingly iso
lated, alone, and fearful.
Open and honest answers to the child's questions
125
about his illness may relieve at least some of the child's
fantasies and distortions about his illness, fantasies
that may well be unreal and cause the child very great but
unnecessary pain.
Although the child may not yet grasp the concept
of death in an adult fashion, the child in this age group
has very real concerns about his fatal condition which
cause him great anxiety, concerns which are very much
related to the seriousness of the illness. Failure on the
part of adults to answer such a child's questions may lead
the child into his own withdrawn world of isolation, fear,
and the accompanying fantasies surrounding his future.
Answering the child's questions openly and honestly may
give the child the needed trust and communication with the
meaningful adults in his environment that will keep him
from withdrawing into this very painful world of inner
fantasy and isolation.
Granted that children may benefit from a permission
to acknowledge their fears openly and from a more frank
discussion with them related to their concerns about their
body integrity and functioning, how is this to be carried
out? Many parents may feel incapable of dealing directly
with their child's questions and of coping with their own
anxiety raised by these questions; as a result, they may
feel a need for professional help in knowledge of the
methods and words to use which would be most appropriate to
126
the child and which would help them face their own anxi
eties relating to the illness. This suggests that a con
tinuing relationship with professional hospital personnel
could be helpful both in anticipating and in meeting the
situation constructively.
Some parents may not have the personal resources
for this type of discussion with their fatally ill child.
A sympathetic professional person could assist both parents
and child when such a need is communicated on the part of
the parents or of the child.
The questions and concerns which are conscious to
the child should be dealt with in such a way that the child
does not feel further isolated and alienated from his
parents and other meaningful adults in his environment.
Although this study was designed to supply addi
tional data on which to base professional decisions on how
to deal with the dying child, much more extensive informa
tion is needed as to the child's methods of communicating
his fears about his illness, and the adult's manner of
communicating with the child about his very real concerns.
To the maximum feasible extent, efforts should be under
taken to prevent or ameliorate harmful effects on the child
that may be caused by the hospitalization and other pro
cedures related to the treatment of his illness.
Answers to the question of how to alleviate the
child’s anxiety are dependent in part on whether the
anxiety is due to the child's perception of the anxiety of
the adults in his environment, to his own inner awareness
of the threat to his body integrity, to fantasies about his
illness, or to a combination of all of these factors.
Further research is called for in implementing various
methods of approaching the questions of the dying child,
and of studying their effectiveness in mitigating the
anxiety of the child. Much needs to be learned toward a
more unified and effective approach to the care of children
facing a fatal prognosis, and to the development of methods
to mitigate effects harmful to the child's psychological
health and development.
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128
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APPENDICES
140
APPENDIX A
INK SKETCHES OF PICTURES USED IN
PROJECTIVE TEST
141
142
OWE
uf/lT
APPENDIX B
SCORING SYSTEM— STORIES
143
SCORING SYSTEM— STORIES
The framework of the scoring system for the stories
told in the projective tests (PIX and 3D) was based on that
adapted by Waechter (1968) from McClelland, Atkinson, Clark
& Lowell (1958), and takes into account the following:
anxiety as expressed by the child in a situation which
could be perceived as threatening, the methods used by the
child in coping with the stress, actions taken toward
relief or reduction of fear, and problems anticipated in
reduction of insecurity about present and future events.
The scoring system is designed to determine the total
amount of preoccupation with threat to body integrity and
functioning.
There were the following possible points per story:
(1) loneliness or separation imagery (LONL), (2) imagery
relating to intrusion into body integrity and functioning,
or mutilation (MUTL), (3) death imagery (DEATH), (4)
present negative affective state (NAS), and (5) negative
anticipatory goal state (NAGS). The categories are
explained as follows.
Loneliness or separation imagery (LONL) is scored
if the child expressed fear of separation from significant
144
145
figures.
Mutilation imagery (MUTL) is scored for a state
ment directly stating or implying body intrusion, bleeding
or breaking of skin.
A reference to death or dying by use of any word
directly stating the concept of death is scored as death
imagery (DEATH).
Negative affective state (NAS) is scored if there
is present in the story a statement of the main character
experiencing pain, fear, or sadness related to present
body functioning or integrity, or related to the course of
current events.
Negative anticipatory goal state (NAGS) is scored
if there is present in the story a statement of the main
character of fear or anxiety about not getting well as a
definite possibility for the future. A score for this
category will be made if there is a statement or thought of
the main character that he might not or will not get well,
or that he will not go home, or that he will need to return
to the hospital, if there is anxiety over survival or a
deepening of the illness or threat, or if there is a state
ment of fear of unsuccessful outcome of events or fear of
potential harm or loneliness.
A score of "blocking" (b), worth one point for each
"block," was given when the judges felt that the child did
not respond to questions in a manner in keeping with his
146
responses throughout the remainder of the test protocol.
Example One: a child has been speaking quite
actively during the first two pictures, and becomes sud
denly silent when presented with the third picture, depict
ing a girl in the hospital, with a nurse at the stand. The
question "What is happening in this picture?" is met with
a 15-second pause, and followed with a barely audible "I
don't know."
Example Two: a child speaks actively about the
contents of the hospital room in the 3D protocol, describ
ing what is in the room. The question "What is your little
friend thinking about all by himself in the hospital?" is
followed by a 15-second pause and an almost tearful "I
don't know."
A blocking response was scored as such only upon
unanimous agreement by all three judges that the child was
not responding to certain parts of the protocol in the same
manner as he had responded to earlier parts. The scoring
was only made when the child either made no response or a
response of "I don't know" and was never made for any
other response, no matter how inappropriate.
It was decided that a score of one point would be
given to each "block" response as a conservative measure of
the least possible score that a negative response would
have drawn at that point.
Data Tables are given in the Appendices that
follow.
APPENDIX C
FLOOR GRID FOR MEASURE OF PERSONAL SPACE
148
Door
Bureau
Bed
Bathroom Couch
149
APPENDIX D
STATE-TRAIT ANXIETY INVENTORY FOR CHILDREN
150
I
i
STAIC FORM C-l
1. I feel Very calm Calm Not calm
2. I feel Very upset Upset Not upset
3. I feel Very pleasant Pleasant Not pleasant
4. I feel Very nervous Nervous Not nervous
5. I feel Very jittery Jittery Not jittery
6. I feel Very rested Rested Not rested
7. I feel Very scared Scared Not scared
8. I feel Very relaxed Relaxed Not relaxed
9. I feel Very worried Worried Not worried
10. I feel Very satisfied Satisfied Not satisfied
11. I feel Very frightened Frightened Not frightened
12. I feel Very happy Happy Not happy
13. I feel Very sure Sure Not sure
14. I feel Very good Good Not good
15. I feel Very troubled Troubled Not troubled
16. I feel Very bothered Bothered Not bothered
17. I feel Very nice Nice Not nice
18. I feel Very terrified Terrified Not terrified
19. I feel Very mixed-up Mixed-up Not mixed-up
20. I feel Very cheerful Cheerful Not cheerful
Copyr ght © 1970 by Dr. C. D. Spielberger, Florida
State University, Tallahassee, Florida.
151
152
STAIC FORM 0 2
1. I worry about making
mistakes Hardly ever Sometimes Often
2. I feel like crying Hardly ever Sometimes Often
3. I feel unhappy Hardly ever Sometimes Often
4. I have trouble
making up my mind Hardly ever Sometimes Often
5. It is difficult for
me to face my
problems Hardly ever Sometimes Often
6. I worry too much Hardly ever Sometimes Often
7. I get upset at home Hardly ever Sometimes Often
8. I am shy Hardly ever Sometimes Often
9. I feel troubled Hardly ever Sometimes Often
10. Unimportant thoughts
run through my mind
and bother me Hardly ever Sometimes Often
11. I worry about school Hardly ever Sometimes Often
12. I have trouble
deciding what to do Hardly ever Sometimes Often
13. I notice my heart
beats fast Hardly ever Sometimes Often
14. I am secretly afraid Hardly ever Sometimes Often
15. I worry about my
parents Hardly ever Sometimes Often
16. My hands get sweaty Hardly ever Sometimes Often
17. I worry about things
that may happen Hardly ever Sometimes Often
18. It is hard for me to
fall asleep at night Hardly ever Sometimes Often
19. I get a funny
feeling in my
stomach Hardly ever Sometimes Often
20. I worry about what
others think of me Hardly ever Sometimes Often
APPENDIX E
THE CHILDREN'S EMBEDDED FIGURES TEST
153
THE CHILDREN'S EMBEDDED FIGURES TEST
INSTRUCTIONS FOR ADMINISTRATION
Materials
1. Simple Figures; Cutout models of the two forms (TENT
and HOUSE) which are embedded in the complex figures.
Each of these forms is the basis for one test series.
2. Demonstration Figures: Three incomplete pictures/
representing stages of embedding a simple figure in a
complex one.
3. Discrimination Figures; A set of 8 plates, each of
which shows a Simple Figure and three similar, but
obviously incorrect, forms.
4. Example Figures; Practice complex figures which are
designed to illustrate the procedure for the child.
5. Test Figures: A series of complex figures, 11 of which
(Ta - Tb) Have the simple TENT figure embedded and 14
of which (HI - H14) have the simple HOUSE figure
embedded.
Procedure
1. Discrimination Series
The first simple cutout figure is presented and S
is told: “This looks something like a TENT, doesn't
it? This black line at the bottom shows where our TENT
rests on the ground. See if you can find another TENT
that looks exactly like ours on this page."
The examiner then presents the first of the four
TENT discrimination plates and encourages the child to
make a choice. The cutout is then placed over his
choice by the S and they are compared. Whether or not
the choice is correct, E and S examine each of the
alternatives on the page and have the child state why
each distorted figure is incorrect. The concept of
correct shape, size and orientation is stressed
throughout.
154
The child is shown the four successive discrimina
tion plates until he understands the procedure. If S
requires additional trials, the plates are used over
again.
Demonstration Series
The TENT discrimination series is followed by a
demonstration of the process of embedding a TENT
figure, using demonstration figures a-c. The child is
first shown the cutout TENT along with demonstration
figures a and b. He is asked to find the TENT in a and
then in b. E tells him as he proceeds from a to b
(and from b to c) that the TENT is becoming hidden more
and more. Following c, E describes the methods used
to hide the simple figures in a, b and'c, to put across
the concept that the simple figure need not be of solid
color or may be intersected or subdivided by lines and
colors when it is hidden in the complex figure.
Training Series
The first example figure (Txl) is presented and S
is told: "A TENT exactly like ours is hiding somewhere
in this picture. The idea of our game is to find the
hidden TENT."
The child is permitted to retain the simple figure
cutout throughout the testing series. When he indi
cates his choice, he is asked to place the simple
figure (TENT) on top of his exact choice.
Txl is followed by Tx2, with identical directions.
Test Series
All subjects are given the full test, Tent a - Tent
6. Responses are scored on a pass or fail basis and a
child is credited with passing an item only when his
first choice is the correct one. A time limit of 60
seconds is set for a scored response of pass, even
though the child may take as long as he wishes to find
the figure.
Following completion of the TENT figures, the
entire procedure is repeated for the HOUSE series (HI -
H14), with the TENT cutout being replaced with the
HOUSE cutout.
The total score represents the sum of all passed
items.
APPENDIX F
MISSING SCORES
156
MISSING SCORES
All of the children in the study completed the
entire four parts of the test protocol in one sitting with
the exception of the following four subjects: C5, C8,
C12 and C14.
Subject C5 asked to leave the room at the comple
tion of the 3D protocol. He did not want to play the
games because he was too tired. When approached later in
the same day and again the following morning, the subject
responded to the examiner with a smile and with conversa
tion but spontaneously interjected that he did not want to
"play1 ' any more with those games. Accordingly, the HOSP-
HOME and CEFT protocols were not administered to subject
C5.
Subject C8 likewise said that he was too tired to
play any further after he had finished part 3D of the
protocol. As with subject C5, so too subject C8 smiled at
the examiner later that same day and again the following
morning but without prompting or any reference to the
"games" stated that he did not wish to come back and "play"
those games any more. The HOSP-HOME and CEFT parts of the
test protocol were not administered to C8.
157
158
Subject C12 finished parts PIX and 3D and HOSP of
the protocol but appeared a little disturbed by the end of
the HOSP protocol. When presented with the HOME question
naire, he refused to answer any of the questions, but
wanted to play with the puzzle (CEFT). After the adminis
tration of the CEFT the examiner again asked the subject
if he wished to take the HOME part of the protocol. The
subject did not wish to do so.
Subject C14 remained virtually silent throughout
the presentation of PIX and 3D, except for a few scattered
"I don't know" phrases. Since the subject appeared dis
turbed at the end of the presentation of the 3D, the
testing session was stopped, and the subject was returned
to his room. The experimenter spent quite a bit of time
with the subject at this point playing non-test-related
games, until the subject was calm and had gotten back his
normal composure. Later in the same day, the examiner went
back to the subject's room and played the CEFT "puzzle"
with him, at his own request. The items HOSP and HOME were
not attempted.
A system had to be devised for giving scores to the
subjects, because a score of zero would have belied the
obvious anxiety; computer programming complexities pre
cluded omitting these scores without also dropping the
subjects' other scores from the analysis. Accordingly, it
was decided by the judges to score in the following manner.
159
For the two subjects who did not attempt the CEFT, C5 and
C8r the average score for leukemic subjects of that age
level on the CEFT measure was assigned as their score.
For the three subjects who did not take the HOSP or
HOME (C5, C8, C14) and the one subject who did not take the
HOME (C12) the average score for the leukemic subjects in
the same cell at that age level was given as a score.
Although the refusal to take the HOSP and HOME
protocols suggested a higher-than-average anxiety level, it
was decided by the judges to give the most conservative
score, the average score of subjects in the same cell at
that age level.
The virtual silence and behavior of subject C14 was
judged as indicative of a high level of anxiety. Accord
ingly, it was decided by the judges to score the subject's
PIX and 3D, but in the most conservative manner, with the
minimum score that scored responses would have measured,
even though these scores were below the average score for
that age level in the same cell. Subject C14 was assigned
a score of 12 for PIX, 8 for 3D.
APPENDIX G
INCIDENTAL DATA
160
INCIDENTAL DATA
Use of Phrase "I don't Know"
An analysis of variance was performed on the number
of times the study subjects had used the phrase "I don’t
know" throughout the story telling portions of the test
protocol, items PIX and 3D. Means and standard deviations
for the use of the phrase are given in Tables 19 and 20.
The results of the analysis of variance are given in Tables
21 and 22. There were no significant differences either
between fatal and non-fatal, or between first and subse
quent admissions in the amount of times subjects used the
phrase "I don't know."
Number of Words
A further analysis of variance was performed on the
number of words used in the stories, both in PIX and in 3D.
Means and standard deviations for the number of words are
given in Tables 23 and 24. The results of the analysis of
variance are given in Tables 25 and 26. There were no
significant differences in the number of words used in the
PIX story telling, either between fatal and non-fatal, or
between first and subsequent hospital admissions. There
was a significant difference in the number of words used in
161
162
TABLE 19
SUMMARY OP MEANS AND STANDARD DEVIATIONS FOR USE OF
THE PHRASE "I DON'T KNOW” IN PROJECTIVE
TEST, PICTURES (PIX)
Leukemic Chronic
First Adm. m
=
2.78 m = 1.56
m = 2.16 SD
=
3.42 SD = 1.33
Subseg. Adm. m 3.13 m = 2.44
m = 2.78 SD
=
3.90 SD = 2.60
m
=
3.00 m = 2.12
overall mean = 2.56
TABLE 20
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR USE OF
THE PHRASE "I DON'T KNOW” IN PROJECTIVE
TEST, THREE-DIMENSIONAL
Leukemic Chronic
First Adm. m = 1.78 m = 0.78
m = 1.28 SD = 2.28 SD = 0.83
Subseg. Adm, m = 2.31 m = 1.44
m = 1.88 SD = 3.24 SD = 1.90
ra = 2.12 m - 1.20
overall mean = 1.66
163
TABLE 21
SUMMARY OF ANALYSIS OF VARIANCE FOR USE OF THE
PHRASE "I DON'T KNOW" IN PROJECTIVE
TEST, PICTURES (PIX)
Source df Mean Squares F
Regression 2 4.05 0.42
L
(I.euk/non-Leuk)
1 11.70 1.20
V
(First/Subseq.)
1 4.02 0.41
L X V 1 0.82 0.08
Error 44 9.71
TABLE 22
SUMMARY OF ANALYSIS OF VARIANCE FOR USE OF
PHRASE "I DON'T KNOW" IN PROJECTIVE
TEST, THREE-DIMENSIONAL
THE
Source df Mean Squares F
Regression 2 6.39 1.14
L 1 9.97 1.78
(Leuk/non-Leuk)
V 1 3.21 0.58
(First/Subseq.)
L X V 1 0.06 0.01
Error 44 5.60
164
TABLE 23
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR NUMBER OF
WORDS USED IN STORY TELLING IN PROJECTIVE
TEST, PICTURES (PIX)
Leukemic Chronic
First Adm. m
=
117.33 m
=
91.22
m = 104.28 SD
=
76.12 SD
=
51.13
Subseq. Adm. m 134.94 m
=
95.75
m = 115.34 SD = 167.80 SD
=
34.83
m 128.60 m
—
94.12
overall mean = 111.30
TABLE 24
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR NUMBER OF
WORDS USED IN STORY TELLING IN PROJECTIVE
TEST, THREE-DIMENSIONAL
Leukemic Chronic
First Adm. m = 135.11 m — 84.56
m = 109.83 SD = 123.63 SD * 50.33
Subseq. Adm. m = 153.94 m = 89.44
m = 121.69 SD a 173.58 SD = 46.63
m = 147.16 m — 87.68
overall m = 117.42
165
TABLE 25
SUMMARY OF ANALYSIS OF VARIANCE FOR NUMBER OF
WORDS USED IN STORY TELLING IN PROJECTIVE
TEST, PICTURES (PIX)
Source df Mean Squares F
Regression 2 56897.53 6.37*
L
(Leuk/non-Leuk)
1 14482.50 1.62
V
(First/Subseq.)
1 3458.56 0.39
L X V 1 648.00 0.07
Error 44 8876.70
*p < .004
TABLE 26
SUMMARY OF ANALYSIS OF VARIANCE FOR NUMBER
WORDS USED IN STORY TELLING IN PROJECTIVE
TEST, THREE-DIMENSIONAL
OF
Source df Mean Squares F
Regression 2 88233.13 8.62*
L
(Leuk/non-Leuk)
1 45694.88 4.46**
V
(First/Subseq.)
1 4551.69 0.44
L X V 1 791.13 0.08
Error 44 10263.35
*p < .001
**p < .040
166
the 3D story telling between fatal and non-fatal (F = 4.46;
p < .040), with the leukemic children using the most words
on the average in their story telling.
A further analysis of variance was performed on the
number of pauses used between the lead questions and the
child's responses (latency score). A score of 3 was given
to each latency of 15 seconds or longer, a score of 2 for
each latency of 10-14 seconds, and a score of 1 for each
latency of 6-9 seconds. Latencies of less than 6 seconds
were not scored. The weighted scores were analyzed. The
means and standard deviations for the latency scores,
weighted, are given in Tables 27 and 28. The results of
the analysis of variance are given in Tables 29 and 30.
The number and duration of pauses (latency) by the
fatally ill children, when compared to the chronically ill
children in the PIX protocol, were significant to .002
level, with an F score of 10.52. The number and duration
of pauses (latency) by the fatally ill children, when com
pared to the chronically ill children in the 3K) protocol,
were significant to the .001 level, with an F score of
13.54. Despite the fact that there were no significant
differences in the use of the phrase "I don't know" in the
PIX and 3D protocols, the fatally ill children paused more
frequently and at greater duration in their story telling
than did the chronically ill children in the control
groups. This factor lends further credence to the
167
TABLE 27
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR LATENCY
SCORES IN STORY TELLING IN PROJECTIVE
TEST, PICTURES (PIX)
Leukemic Chronic
First Adm. m
=
10.56 m = 1.89
m = 6.22 SD
=
9.00 SD = 2.32
Subseq. Adm. m
=
6.63 m = 2.88
m = 4.75 SD
=
9.51 SD = 4.41
m
=
8.04 m = 2.52
overall mean = 5.28
TABLE 28
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR LATENCY
SCORES IN STORY TELLING IN PROJECTIVE
TEST, THREE-DIMENSIONAL
Leukemic Chronic
First Adm. m = 8.78 m = 0.44
m = 4.61 SD = 6.70 SD = 0.88
Subseq. Adm. m = 3.38 m = 1.81
m = 2.59 SD = 4.32 SD = 3.10
m = 5.32
overall mean =
m =
3.32
1.32
168
TABLE 29
SUMMARY OF ANALYSIS OF VARIANCE FOR LATENCY
SCORES IN STORY TELLING IN PROJECTIVE
TEST, PICTURES (PIX)
Source df Mean Squares F
Regression 2 141.80 3.03
L
(Leuk/non-Leuk)
1 491.63 10.52*
V
(First/Subseg.)
1 21.89 0.47
L X V 1 66.64 1.43
Error 44 46.62
*p < .002
TABLE 30
SUMMARY OF ANALYSIS OF VARIANCE FOR LATENCY
SCORES IN STORY TELLING IN PROJECTIVE
TEST, THREE-DIMENSIONAL
Source df Mean Squares F
Regression 2 39.52 2.34
L
(Leuk/non-Leuk)
1 228.62 13.54*
V
(First/Subseq.)
1 49.42 2.93
L X V 1 131.46 7.79**
Error 44 16.94
*p < .001
**p < .008
169
hypothesis that the leukemic children in the study sample
were more anxious in their responses to the PIX and 3D
portions of the protocol than were the chronically ill
children. The conclusion is based on evidence that latency
of response to possible anxiety-provoking questions is
symptomatic of anxiety.
Blocking Responses
A further analysis of variance was performed on the
number of times scores of "blocking" were given to the
children in the protocol. The "blocking" responses were
unanimously agreed upon by the judges, and given a score
of one per "block." Means and standard deviations are
given in Tables 31 and 32. The results of the analysis of
variance are given in Tables 33 and 34.
The number of times the fatally ill children were
scored as having "blocked" in their responses, compared to
the chronically ill children in the PIX protocol, was
significant to the .001 level, with an F score of 29.37.
The number of times the fatally ill children were scored as
having "blocked" in their responses, compared to the
chronically ill children in the 3D protocol, was signifi
cant to the .001 level, with an F score of 18.88. The
fatally ill children were judged as having "blocked" in
their responses a significantly greater number of times
than the chronically ill children in the story telling
170
TABLE 31
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR
BLOCKING RESPONSES IN STORY TELLING IN
PROJECTIVE TEST, PICTURES (PIX)
Leukemic Chronic
First Adm. m
-
3.11 m = 0.44
m = 1.78 SD
=
2.37 SD = 0.73
Subseq. Adm. m
=
3.38 m = 0.19
m = 1.78 SD
=
2.85 SD = 0.54
m
=
3.28 m = 0.28
overall mean = 1.78
TABLE 32
SUMMARY OF MEANS AND STANDARD DEVIATIONS FOR
BLOCKING RESPONSES IN STORY TELLING IN
PROJECTIVE TEST, THREE-DIMENSIONAL
Leukemic Chronic
First Adm. m = 1.78 m = 0.11
m = 0.94 SD = 2.11 SD = 0.33
Subseq. Adm. m = 2.06 m = 0.19
m * 1.13 SD = 2.05 SD = 0.40
m = 1.96
overall mean =
m =
1.06
0.16
171
TABLE 33
SUMMARY OF ANALYSIS OF VARIANCE FOR BLOCKING
RESPONSES IN STORY TELLING IN PROJECTIVE
TEST, PICTURES (PIX)
Source df Mean Squares F
Regression 2 4.61 1.22
L
(Leuk/non-Leuk)
1 110.87 29.37*
V
(First/Subseq.)
1 0.03 0.01
L X V 1 0.74 0.20
Error 44 3.86
*p < .001
TABLE 34
SUMMARY OF ANALYSIS OF VARIANCE FOR BLOCKING
RESPONSES IN STORY TELLING IN PROJECTIVE
TEST, THREE-DIMENSIONAL
Source df Mean Squares F
Regression 2 6.66 3.31*
L
(Leuk/non-Leuk)
1 37.98 18.88**
V
(First/Subseq.)
1 0.14 0.07
L X V 1 0.10 0.05
Error 44 2.02
*p < .046
**p < .001
172
related to both the PIX and the 3D parts of the test pro
tocol.
Correlations
Correlation of the various measures (Table 35)
shines some light on the foregoing measures. First,
BLOCKS-PIX correlated very highly with BL0CKS-3D (0.84);
LATENCY-PIX correlated with LATENCY-3D (0.53); and the use
of the phrase "I don't know" for PIX (IDN-PIX) correlated
highly with IDN-3D (0.74). The two story-telling portions
of the test protocol seemed to tap the same types of
resources and measures in the subjects telling the stories.
Secondly, the number of blocks in the PIX portion
of the protocol (BLK-PIX) correlated negatively with the
number of words (WDS-PIX) used in PIX (-0.36), while the
number of blocks in the 3D protocol (BLK-3D) also corre
lated negatively with the number of words (WDS-3D) used in
3D (-0.34). It seems that those children, both fatal and
non-fatal, who received the highest "block" scores were
also those who spoke the fewest words. Despite the fact
that the leukemic children in the 3D protocol spoke
significantly more words than their chronically ill
counterparts, those leukemic children who spoke the fewest
words, comparatively speaking, were also the ones judged to
have the greatest number of "blocks" in their responses.
Thirdly, the number of blocks in PIX (BLK-PIX)
TABLE 35
CORRELATION MATRIX FOR 8 VARIABLES, COV. AGE--GRADE
IDN- WDS- LAT- IDN- WDS- LAT- BLK- BLK-
PIX PIX PIX 3D 3D 3D PIX 3D
IDN-PIX 3.1 +
WDS-PIX 0.03 94 +
LAT-PIX -0.15 - 0.27 6.8 +
IDN-3D 0.74 - 0.18 -0.08 2.3 +
WDS-3D -0.08 0.65 -0.24
l
o
•
o
cn
101 +
LAT-3D -0.01 - 0.18 0.53 C.14 - 0.28 4.1 +
BLK-PIX 0.37 - 0.36 0.36 0.55 - 0.22 0.35 1.9 +
BLK-3D 0.28 - 0.32 0.31 0.51 - 0.34 0.46 0.84 1.4 +
174
correlated positively with the number of "I don’t know"
phrases (IDN-PIX) used in PIX (0.37), while the number of
blocks used in 3D (BLK-3D) correlated positively with the.
number of "I don't know" phrases (IDN-3D) used in 31)
(0.51), for all of the children in the study protocol.
Finally, LAT-PIX correlated positively with BLK-PIX
(0.36), while LAT-3D correlated positively (0.46) with
BLK-3D. The children who paused the longest and most
frequently were also those who were judged as having the
greatest number of "blocking" responses.
APPENDIX H
RAW DATA
175
TABLE 36
RAW DATA FOR STORY TELLING SCORES ON
PROJECTIVE TEST, PICTURES
BLOCKS NAS NAGS LONL MUTL DEATH TOTAL
Leukemic
A1 6 1 0 0 0 0 7
A2 2 0 0 0 0 0 2
A3 7 1 0 0 0 0 8
A4 0 3 0 0 3 0 6
A5 1 4 1 0 6 0 12
A6 5 10 0 3 8 0 26
A7 2 4 1 0 3 0 10
AS 2 9 0 0 4 0 15
A9 3 5 0 0 2 0 10
Cl 8 0 0 0 0 0 8
C2 7 0 0 0 0 0 7
C3 1 2 0 0 2 0 5
C4 1 4 0 0 2 0 7
C5 7 1 0 0 2 0 10
C6 4 1 0 0 1 0 6
C7 0 0 0 0 1 0 1
C8 7 0 0 0 0 0 7
C9 6 1 0 0 0 0 7
CIO 4 1 2 0 0 0 7
Cll 0 16 1 5 4 0 26
C12 1 5 1 0 1 0 8
C13 1 7 1 3 1 0 13
C14 12 0 0 0 0 0 12
C15 2 13 1 0 4 0 20
C16 1 13 0
Chronic
0 2 0 16
B1 0 0 0 0 0 0 0
B2 0 0 1 0 1 0 2
B3 0 1 0 0 0 0 1
B4 0 0 0 0 0 0 0
B5 1 0 0 0 1 0 2
B6 2 1 0 0 2 0 5
B7 0 1 0
176
0 1 0 2
TABLE 36— Continued
177
BLOCKS NAS NAGS LONL MUTL DEATH TOTAL
Chronic
B8 0 1 0 0 0 0 1
B9 1 4 2 1 0 1 9
Dl 0 0 0 0 0 0 0
D2 0 1 0 0 0 0 1
D3 0 0 0 0 0 0 0
D4 0 1 0 0 3 0 4
D5 0 0 0 0 1 0 1
D6 0 0 1 0 3 0 4
D7 0 0 1 0 3 0 4
D8 0 2 1 0 0 0 3
D9 1 6 0 0 1 0 8
DlO 0 0 0 0 1 0 1
Dll 0 7 0 1 4 0 12
D12 0 5 1 0 5 0 11
D13 2 0 0 0 1 0 3
D14 0 3 0 0 1 0 4
D15 0 0 0 0 1 0 1
D16 0 4 0 0 0 0 4
178
TABLE 37
RAW DATA FOR STORY TELLING SCORES ON PROJECTIVE
TEST, THREE-DIMENSIONAL
BLOCKS NAS NAGS LONL MUTL DEATH TOTAL
Al 5 4
Leukemic
1 0 0 0 10
A2 3 0 0 0 0 0 3
A3 5 0 0 0 0 0 5
A4 0 3 0 2 0 0 5
A5 0 2 2 0 6 0 10
A6 0 7 2 0 3 0 12
A7 0 8 0 2 3 0 13
A8 1 6 2 4 3 0 16
A9 2 6 1 0 0 0 9
Cl 5 0 0 0 0 0 5
C2 4 0 0 0 0 0 4
C3 0 2 0 0 3 0 5
C4 2 3 0 0 2 0 7
C5 5 1 0 0 0 0 6
C6 4 7 0 0 0 0 11
C7 0 2 0 0 5 0 7
C8 5 0 0 0 0 0 5
C9 4 1 0 0 0 0 5
CIO 1 2 1 0 2 0 6
Cll 0 17 0 0 6 0 23
C12 0 1 2 0 0 0 3
C13 1 12 1 6 0 0 20
C14 8 0 0 0 0 0 8
C15 1 4 0 0 0 0 5
C16 0 12 3 0 8 0 23
B1 0 0
Chronic
0 0 0 0 0
B2 0 0 0 0 0 0 0
B3 0 1 0 0 0 0 1
B4 0
A
0 0 0 0 4
B5
1
J. 0 0 0 1 0 2
B6 0 0 0 0 0 0 0
B7 0 1 0 0 1
n
V
B8 0 2 0 1 1 0 4
179
TABLE 37— Continued
BLOCKS NAS NAGS LONL MUTL DEATH TOTAL
Chronic
B9 0 3 2 0 0 0 5
Dl 0 0 2 0 0 0 2
D2 0 1 0 0 0 0 1
D3 0 0 0 0 0 0 0
D4 1 0 0 0 1 0 2
D5 0 2 0 0 2 0 4
D6 0 0 0 0 2 0 2
D7 0 1 0 0 2 0 3
D8 0 4 0 0 0 0 4
D9 1 2 0 0 1 0 4
DIO 0 0 0 0 1 0 1
Dll 0 1 0 0 1 0 2
D12 0 2 0 2 0 0 4
D13 1 1 0 0 1 0 3
D14 0 1 0 0 0 0 1
D15 0 1 0 0 4 0 5
D16 0 2 0 0 0 0 2
180
RAW DATA
TABLE 38
FOR HOSP, HOME AND CEFT SCORES
Leukemic Chronic
HOSP HOME CEFT HOSP HOME CEFT
A1 39 15 20 Bl 0 2 15
A2 25 4 18 B2 3 8 5
A3 16 12 17 B3 7 9 8
A4 27 11 10 B4 13 2 17
A5 24 20 21 B5 15 11
13
A6 21 20 23 B6 7 12 22
A7 28 18 21 B7 10 12 22
A8 18 17 25 B8 14 20 19
A9 12 14 20 B9 6 11 25
Cl 18 9 8 Dl 15 5 8
C2 15 10 3 D2 2 2 7
C3 12 14 8 D3 9 1 17
C4 12 8 16 D4 10 4 11
C5 15 13 17 D5 2 11 3
C6 23 14 19 D6 9 0 15
C7 12 19 18 D7 12 26 14
C8 20 18 18 D8 11 15 20
C9 26 20 18 D9 11 5 17
CIO 14 3 19 D10 6 12 17
Cll 20 29 20 Dll 4 8 22
C12 20 13 25 D12 4 24 16
C13 12 9 25 D13 20 6 20
C14 20 18 23 D14 12 5 21
C15 18 27 21 D15 13 12 20
C16 11 16 24 D16 7 17 24
181
TABLE 39
RAW DATA FOR MEASURES OF PERSONAL SPACE USUAL
Leukemic Chronic
NURS DCTR MTHR FTHR NURS DCTR MTHR FTHR
A1 0.25 0.50 1.50 1.25
A2 1.00 1.25 4.00 2.00
A3 3.25 0.25 3.25 3.50
A4 0.75 1.00 1.00 1.00
A5 1.00 2.00 1.75 1.50
A6 1.00 1.25 2.00 0.25
A7 0.25 0.25 0.25 0.25
A8 3.00 0.50 0.50 3.00
A9 1.25 1.00 1.50 1.00
Cl 3.00 5.00 0.50 0.75
C2 4.50 6.00 3.50 3.75
C3 0.50 0.50 8.00 7.00
C4 4.25 5.75 4.25 4.25
C5 8.25 7.00 6.50 6.50
C6 3.50 3.00 0.75 0.50
C7 5.00 1.50 1.00 1.00
C8 8.00 1.50 1.00 2.00
C9 4.10 2.00 3.00 4.00
CIO 1.75 1.00 1.00 1.75
Cll 1.50 3.50 3.75 3.75
C12 0.25 0.25 1.25 1.25
C13 2.50 2.00 1.00 1.00
C14 0.50 0.75 8.00 3.50
C15 2.50 5.70 5.20 5.70
C16 2.25 2.00 4.00 3.50
Bl 1.00 1.50 4.00 5.00
B2 0.75 1.00 0.75 5.50
B3 0.75 0.75 1.25 1.00
B4 2.00 0.25 0.25 0.25
B5 1.30 0.25 0.25 0.25
B6 2.00 2.00 1.00 1.00
B7 1.25 0.75 1.75 1.75
B8 0.75 1.00 2.00 2.00
B9 1.00 0.25 0.25 0.25
Dl 1.30 0.80 1.50 1.00
D2 1.00 1.50 1.50 0.50
D3 1.00 1.00 0.75 0.75
D4 4.50 1.00 1.00 1.00
D5 1.75 3.25 3.25 3.25
D6 2.50 3.00 2.00 2.00
D7 1.50 2.00 2.00 2.00
D8 1.00 1.00 2.00 2.00
D9 1.50 0.50 2.00 2.50
D10 1.00 1.00 1.50 1.50
Dll 2.00 3.80 3.80 4.00
D12 1.00 1.00 1.50 1.00
D13 1.00 0.50 0.75 1.25
D14 2.75 5.00 3.25 1.50
D15 0.25 0.25 0.25 0.25
D16 4.00 0.50 2.00 1.50
182
TABLE 40
RAW DATA FOR MEASURES OF PERSONAL SPACE LIKE
Leukemic Chronic
NURS DCTR MTHR FTHR NURS DCTR MTHR FTHR
A1 0.25 0.50 1.50 1.25
A2 1.00 1.25 4.00 2.00
A3 3.25 0.25 3.25 3.50
A4 0.75 1.00 1.00 1.00
A5 5.00 2.25 1.75 1.50
A6 1.00 0.50 2.00 0.25
A7 5.25 5.25 0.25 0.25
A8 5.00 9.99 0.50 0.25
A9 1.25 1.00 1.50 1.00
Cl 3.00 5.00 0.50 0.75
C2 4.50 6.00 3.50 3.75
C3 4.50 8.50 5.50 8.00
C4 1.25 2.00 2.75 6.00
C5 8.25 7.00 6.50 6.50
C6 5.00 0.25 0.75 0.50
C7 5.00 1.50 1.00 1.00
C8 8.00 1.50 1.00 2.00
C9 4.10 2.00 3.00 4.00
CIO 1.75 1.00 1.00 1.75
Cll 3.75 9.00 8.25 0.75
C12 0.25 0.25 1.25 1.25
C13 1.00 0.75 0.25 0.25
C14 0„ 50 0.75 8.00 3.50
C15 2= 50 5.70 5.20 5.70
C16 0.50 0.50 0.75 1.00
Bl 1.00 1.50 1.75 1.50
B2 0.75 1.00 0.75 1.50
B3 0.75 0.75 1.25 1.00
B4 2.00 0.25 0.25 0.25
B5 1.30 0.25 0.25 0.25
B6 2.00 2.00 1.00 1.00
B7 1.25 4.50 1.25 0.50
B8 9.99 9.99 0.50 0.50
B9 1.00 0.25 0.25 0.25
Dl 1.00 1.25 1.75 1.00
D2 1.00 1.50 1.50 0.50
D3 1.00 1.50 0.75 0.75
D4 0.25 0.25 1.00 1.00
D5 0.01 0.01 0.01 0.01
D6 2.50 3.00 2.00 2.00
D7 1.50 2.00 2.00 2.00
D8 1.00 1.00 7.50 2.00
D9 1.50 0.50 0.75 1.25
D10 4.00 4.00 0.75 0.50
Dll 0.25 1.50 1.50 0.25
D12 1.50 1.25 1.00 0.75
D13 9.99 9.99 0.25 0.01
D14 2.75 5.00 3.25 1.50
D15 0.25 0.25 0.25 0.25
D16 0.50 0.50 2.00 1.50
183
TABLE 41
RAW DATA FOR SCORES ON USE OF PHRASE "I DON'T KNOW,”
NUMBER OF WORDS, AND NUMBER OF 15, 10-14, AND
6-9 SECOND PAUSES IN PROJECTIVE
TEST, PICTURES
Leukemic Chronic
IDN WPS 15 10+ 6+ IDN WPS 15 10+ 6+
A1 2 46 1 0 1 Bl 3 75 0 0 0
A2 1 38 0 1 2 B2 0 61 0 0 2
A3 7 76 4 4 5 B3 2 39 0 0 0
A4 0 83 0 0 0 B4 1 85 0 0 0
A5 0 111 4 1 2 B5 4 52 0 1 0
A6 2 170 0 1 3 B6 0 81 1 0 4
A7 2 271 0 7 7 B7 1 77 0 1 2
A8 10 182 0 0 4 B8 2 154 0 0 0
A9 1 79 4 2 0 B9 1 197 0 0 1
Cl 14 48 0 0 1 Dl 0 153 0 0 0
C2 7 25 0 1 1 D2 0 103 0 0 0
C3 2 56 0 0 1 D3 5 75 0 0 0
C4 0 133 1 0 0 D4 0 53 1 2 6
C5 0 13 0 6 3 D5 2 75 0 0 1
C6 0 59 3 0 1 D6 6 63 0 1 2
C7 0 56 0 0 0 D7 0 94 0 0 0
C8 7 41 0 0 0 D8 4 87 1 1 7
C9 1 44 8 5 0 D9 2 80 0 0 2
CIO 3 37 6 1 0 D10 2 109 0 0 0
Cll 7 384 1 0 0 Dll 3 98 0 0 0
C12 4 94 0 0 1 D12 0 195 0 0 0
C13 0 304 0 0 2 D13 7 98 0 1 7
C14 1 3 4 0 0 D14 7 90 0 0 1
C15 3 600 0 0 0 D15 1 70 0 1 1
C16 1 262 0 0 1 D16 0 89 0 1 0
184
TABLE 42
RAW DATA FOR SCORES ON USE OF PHRASE "I DON'T KNOW,"
NUMBER OF WORDS, AND NUMBER OF 15, 10-14, AND
6-9 SECOND PAUSES IN PROJECTIVE TEST,
THREE-DIMENSIONAL
Leukemic
IDN WDS 15 10+ 6+
A1 3 39 3 3 1
A2 2 12 0 0 4
A3 7 57 2 5 1
A4 0 49 0 0 0
A5 0 93 3 3 2
A6 2 296 0 0 1
A7 0 333 1 1 4
A8 2 256 0 0 3
A9 0 81 4 0 0
Cl 12 38 0 0 8
C2 4 34 0 0 0
C3 1 65 0 0 0
C4 0 90 1 2 4
C5 0 14 0 5 0
C6 5 96 0 0 3
C7 1 52 0 0 1
C8 6 55 0 0 0
C9 0 16 4 0 0
CIO 1 37 1 0 0
Cll 1 170 0 0 0
C12 0 80 0 0 0
C13 3 465 0 0 1
C14 6 18 1 0 0
C15 0 539 0 0 0
C16 0 312 0 0 2
Chronic
IDN WDS 15 10+ 6+
Bl 2 89 0 0 0
B2 0 44 0 0 0
B3 1 42 0 0 0
B4 1 160 0 0 0
B5 2 36 0 0 2
B6 0 45 0 1 0
B7 0 85 0 0 0
B8 1 169 0 0 0
B9 0 91 0 0 0
Dl 0 141 0 0 0
D2 1 90 0 0 1
D3 2 45 0 0 1
D4 0 32 0 0 1
D5 0 65 0 0 0
D6 4 40 0 6 0
D7 0 102 0 0 0
D8 1 56 0 0 4
D9 0 45 0 1 2
D10 1 124 0 0 0
Dll 1 190 0 0 0
D12 1 127 1 0 0
D13 5 136 0 0 3
D14 6 46 0 0 0
D15 1 119 0 0 0
D16 0 71 0 0 0
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Asset Metadata
Creator
Spinetta, John Joseph
(author)
Core Title
Death Anxiety In Leukemic Children
Degree
Doctor of Philosophy
Degree Program
Psychology
Publisher
University of Southern California
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Marston, Albert R. (
committee chair
), Frankel, Andrew Steven (
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