‘The consultant nearly fell through the floor — she had never heard the child’s voice’

The five-year-old girl was not letting medical staff near her left leg to change the burns bandage, underneath which the dressing can stick to the wound.

“If you can soak it enough, it will come off with less pulling or pain,” explains hospital play specialist Rachel Griffin. But the little girl was screaming if anybody came near to her to put water on it at the clinic in Cork University Hospital (CUH). Doctors were discussing how they would have to administer morphine, which would prolong her time in the hospital.

However, this was not necessary after Griffin engaged the young patient in a great session of water play. By the time the little girl was herself squirting water on the dressing, the play specialist was, with the permission of the doctor, able to peel it back.

“We were singing and I was talking about fire hoses. She was an active participant in her treatment — and it was all through fun,” Griffin tells The Irish Times, after she spoke at a webinar about play for resilience and good mental health, hosted by the charity Children in Hospital Ireland. Chief executive Anna Gunning says, generally people think of play in hospitals as “a luxury and nice thing to do, rather than an essential part of a child’s recovery”.

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Griffin recalls a nine-year-old girl who had been in and out of hospital ever since she was born, yet had never spoken to the doctor who had been treating her all that time. “She refused to speak when anybody entered the room; she would just look down and not talk. Her confidence came with the opportunity to play.”

[ Children in Hospital Ireland loses Government funding ]

As the girl’s life was dominated by time in hospital, Griffin noted she had a lot of interest in playing with medical equipment. She gave her a stethoscope and other items to play with, along with a dolly that the girl christened Polly. Griffin watched as, session after session, the girl “played out her own reality”. There was a Garda escort with the ambulance that was transporting Polly, which is what happened to her.

Play in hospital ‘allows the child and the parent to thaw out a bit and get to grips with their new situation’

“Because she was going for numerous surgeries, if Polly had a surgery and I said ‘she’s all better now’, she said ‘no she’s not, she needs more’, because her reality was no, one surgery doesn’t fix it.” They did a lot of play around these scenarios, with the girl ringing the doctor for Polly, before then becoming the doctor and helping Polly. It came to the point where the girl spoke to her own doctor, pretending to be her and using the doctor’s name: “I’m Dr ‘Mary’ and I’m here to help Polly”, she explained.

“The consultant nearly fell through the floor — she had never heard the child’s voice,” says Griffin. “The play had enabled [the child] to make sense of what was going on around her and gave her a voice.” She was much more confident from then on, greeting people who came into the room and engaging with other staff. When getting a new cannula or having a dressing changed, the girl would do it on Polly in parallel.

“It is probably one of the most powerful and moving stories I have,” says Griffin, who believes there is growing awareness of the importance of play within CUH, where she started to work in 2021 as the lone play specialist. “Everybody is seeing the benefits of playful interactions and strategies that I would use.” She believes the presence of a hospital play specialist encourages other adults to be playful and she sees nurses and doctors picking up techniques from her.

Once a hospitalised child is no longer trapped in ‘fight, flight or freeze’ mode, the full brain is available to address other tasks

Children’s Health Ireland, which governs and operates acute paediatric services for the Greater Dublin Area, as well as all national paediatric services, has just over 22 whole-time-equivalent (WTE) play specialist posts and three WTE play assistant posts across its four sites, says a CHI spokeswoman. They are distributed as follows: 12.75 in Crumlin; 8 in Temple Street; 2.53 in Tallaght and 1 in Connolly, with an additional post approved for the end of this year.

Play is the avenue into the children’s world, says Catherine Matthews, principal clinical psychologist with CHI @ Crumlin, on the webinar. In the hospital environment, children and families are stressed because things are happening out of their control. There’s no predictability; no sense of familiarity and continuity, which children crave.

In paediatric psychology, when children and parents are stuck in a heightened state of anxiety, we’re always guarding against post-traumatic stress disorder, depression, anxiety and excessive worry, she said. Play in hospital “allows the child and the parent to thaw out a bit and get to grips with their new situation”.

[ Play volunteers providing hospitalised children with a crucial distraction ]

Neuropsychology has been able to show how the brains of children react to play. It activates the production of dopamine, “the coping hormone”. It also stimulates the “happy hormone” endorphin, which lowers stress. Once a hospitalised child is no longer trapped in “fight, flight or freeze” mode, the full brain is available to address other tasks, such as impulse control and emotional regulation, and to cope with their immediate circumstances. Play also strengthens relationships between children and caregivers, which is known to aid quicker recovery.

Griffin outlines five types of play used in hospital, while stressing that they are all interlinked:

• Normal play: self-directed play by the child for their own amusement. They are in control, either in the playroom or in using resources brought to their bedside based on their interests and abilities.
• Developmental play: this is particularly important for babies on long-term stays because the 0-2 stage of life is a period of such rapid development. Griffin links with therapists as to what each child needs to work on, to bring them to the next level.
• Therapeutic play: purposeful play led by a play specialist to address, say, the anxieties a child might have. This can evolve from normal play. In creating space for a child to play, she will often see a child start to give information about their emotions and she can then devise therapeutic play to deal with those, or to prepare for what’s ahead and to cope with pain.
• Post-procedural play: this is vital to help children understand and process what has happened to them. She recalls one little boy who came into the playroom with a very cross face and was banging toys around the place. “I said ‘you’re doing a lot of bashing and crashing ...’ I didn’t say he was angry because it pre my place to say he was angry. ‘Yes, I’m really cross with the nurse because she hurt me and I really hate her’.” Griffin helped the boy to understand what had happened, why it had happened and the importance of what the nurse had been doing. “It was almost like I had popped a balloon and you could see him deflating.” The rage was replaced with a bit more understanding. “If that boy had left the hospital here without having that play session, he would have been going home carrying all that anger and frustration, which can have physical repercussions.”
• Rehabilitation play: this gives children the opportunities to practise movements that will aid their recovery and restore their abilities to where they were prior to treatment, such as walking again after surgery or using a healing limb. “A lot of that would be done in conjunction with the occupational therapist — in joint sessions with them.” She remembers one girl who was still holding her burned hand as if it had just happened, when in fact it had healed very well. Whenever she was asked to use it, she would well up in tears and refuse, petrified that it would hurt. Through play and interactions over a number of weeks, Griffin was able to coax her to start using her hand again. It was step by step, she explains, not “full on play” as people might think.

Mother of three Tracy Holmes has a whole new perspective on play after having had a child hospitalised for nearly all the first 13 months of his life. Before that, she took play for granted with her firstborn Harry, who is now aged four. “It was just something you did to have fun.” But her eyes were opened to its deeper impact after the births of her next two children.

Freddie and his non-identical twin brother Theo had to be delivered by Caesarean section at 30 weeks in the National Maternity Hospital. About an hour after the birth, Tracy and her husband Andrew found out that Freddie has Down syndrome. Both boys were in neonatal intensive care for five weeks but, initially, Freddie, born weighing 1.05kg didn’t need any more supports than his heavier brother (1.5kg). It was in NICU the couple first experienced the importance of sensory play.

It was a good experience for Harry to play with Freddie in the hospital and to learn, for coming home, what Freddie was able and not able for

—  Tracy Holmes

“They were saying ‘bring books in and read’ and we were, ‘surely they don’t need that?’.” However, she and Andrew were told it was very important for the boys to be hearing their voices, and that black and white sensory cards around Freddie’s cot would also be helpful. It had been discovered that Freddie couldn’t feed orally, unlike his brother, and he needed oxygen support. An “echo” scan showed he had pulmonary hypertension and, after being transferred to CHI Crumlin in September 2021, at nearly three months old, he was diagnosed with lung disease.

Freddie was linked in with a physio, occupational therapist and speech and language therapist, all of who work through play. “That is when it became evident to us that play is more than just having fun, play was really important,” says Tracy. She and Andrew then pushed for Freddie to receive music therapy, “as we knew how he interacted and how much he responded to music”.

Even though she had seen volunteers from Children in Hospital Ireland going around in red T-shirts, she didn’t know what they were about until Freddie’s first ICU admission last November, where she came across a leaflet in the parents’ room. “That was my first insight into that’s what they are.”

It prompted her to talk to their co-ordinator and from then on the extra support they offered was a huge help. Volunteers would make sure to spend time with Freddie during the “crossover” when Tracy would return home to Greystones, Co Wicklow to regroup and see her other children before her mother, or Andrew, went in to be with him in the evening. During the lengthy hospitalisation, the couple still had a wedding catering business to run.

In the run-up to Freddie’s discharge on July 5th last, the family were given special permission to bring in his siblings to play with him in a private room. Freddie is not as strong as Theo and is still receiving physio to build up his muscle tone. He also continues to be mostly tube fed, “which is unusual for other children to see”, Tracy says.

“It was a good experience for Harry to play with Freddie in the hospital and to learn, for coming home, what Freddie was able and not able for, that he had to be careful of his feeding tube and things like that.” It was helpful to get that learning out of the way, rather than being an extra stress on top of everything else when they got Freddie home.

The “magic” of play continues to be centre stage in the Holmes household and they praise the early intervention services that Freddie received in Bray. His physio noted how motivated he is by play and music.

“It’s hard work for him doing physio and he knows that, he tires doing it,” says Tracy. “It’s good for him to know it is not all negative, there is a play element in it.”