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Therapeutic Touch With HIV-Infected

Children: A Pilot Stud'Y

Mary Ireland, RN, PhD

psychosocial stressors. Those children who have had

In this pilot study, 20 HIV-infected children, 6 to their diagnosis disclosed to them experience the stress
12 years of age, were randomly assigned into thera- of carrying the secret of HIV infection and may feel
peutic touch (TT) and mimic TT groups. The effective- contaminated. When there has been no disclosure, the
ness of TT in reducing anxiety was evaluated. The infected child often suspects something is wrong
self-report measure, the A-State Anxiety subscale of because of the cues picked up from family members
the Spielberger State-Trait Anxiety Inventory For and the frequency of physician visits and treatments
Children, was administered before and immediately and drugs received. The heightened and prolonged
after interventions. As predicted, the TT intervention tension experienced under either condition can evolve
resulted in lower overall mean anxiety scores, into a spiral of unrelieved stress that may be mani-
whereas the mimic TT did not. These findings provide fested in a host of both physical and emotional
preliminary support for the use of TT in reducing the sequelae. Additional stressors that are unique to pedi-
state anxiety of children with HIV infection. atric HIV disease, social isolation, multigenerational
impact, interactions with previous family problems
Key words: Therapeutic touch, children, anxiety.
such as drug addiction, and multiple losses (Lewis
D e s p i t e the significant reduction in mother-to-infant et al., 1994) further intensify the child's trauma
transmission of HIV and the improved health status of accommodation.
infants receiving zidovudine (protocol 076)(Connor Anxiety evokes a stress response and activates the
et al., 1994), a cure for HIV remains elusive, and HIV sympathetic nervous system, which, if sustained,
infection remains a threat to children over the next heightens physiologic and emotional reactivity and
decade (Gallagher & Klima, 1996). At the other end of immunosuppression, and increases infection risk
the perinatally acquired HIV infection continuum are (Caudell, 1996). For these reasons, stress-reduction
the infected children who are living longer. Natural techniques such as muscle relaxation, imagery, bio-
history data on perinatal HIV infection indicates that feedback, and hypnosis have been increasingly
the median survival age has increased from approxi- employed to help alleviate the anxiety that accompa-
mately 6 to 9 years (Grubman et al., 1995). Moreover, nies a range of pediatric conditions. An additional and
there is an emerging population of older children with potentially effective techniqfie is the nurse-developed
later onset of clinical symptoms and prolonged complementary modality called therapeutic touch
survival. (TI'). Research and practice literature suggest that
As HIV-infected children live longer, the stress that through TI', individuals can experience a relaxation
they accumulate may put some at risk for severe emo- response: that is, a deactivation of two classic stress
tional distress (Lewis, Haiken, & Hoyt, 1994; Pol- response pathways, the hypothalamic-pituitary
lack & Thompson, 1995). Because HIV infection is
accompanied by a pervasive stigma that elicits guilt, Mary Ireland, RN, PhD, is an assistant professor at Rutgers
shame, anger, and secrecy, it amplifies the impact of University, College of Nursing.

Copyright 9 1998 Association of Nurses in AIDS Care
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 69

adrenal axis (HPA) and the sympatho-adrenal- not a requirement for assessment and treatment. Nor is
medullary (SAM)axis (Mulloney & Wells-Federman, its effectiveness contingent on the patient's belief in
1996). Eliciting the relaxation response, reducing the intervention.
anxiety, and interrupting the stress-symptom cycle
enhance the body's natural healing process, facilitate TT Research
recovery from illness, and prevent further complica-
tions. Tr, therefore, seems well suited for the treat- Of direct relevance to this study are the landmark
ment of HIV disease. Indeed, recent findings offer investigations of Heidt (1981) and Quinn (1982) who
some support that TI" is not only a useful stress- examined the effect of "IT on anxiety. Although these
reduction intervention but may influence immunosup- two investigators used different procedures for admin-
pression. For example, Garrard (1995) found an istering TT and different control protocols, both found
increase in both coping skills and lymphocyte subset a significant decrease in state anxiety scores on the
pattern among HIV-infected males who had been State-Trait Anxiety Inventory (STAI) (Spielberger,
treated with T'I'. Although 22 healthy yet stressed Gorsuch, & Lushene, 1970) in adult hospitalized car-
medical and nursing students facing professional diovascular patients. After administering the STAI,
board exams showed no significant difference in state Heidt assigned participants to one of three groups on
anxiety scores following three "lq" treatments com- the basis of matching scores. Group A received TI',
pared to a no-treatment group, the "17"group changed Group B casual touch, and Group C no touch. Quinn
in the expected direction and had significantly less randomly assigned subjects to two groups after partici-
decrement in IgA and IgM levels than did controls who pants completed the STAI. One group was treated with
had no treatments (Olson et al., 1997). Despite such TI' and the other with mimic "IT. Both investigators
promising findings with adults, there has been little used rigorous research designs and estimated adequate
empirical investigation about the effectiveness of "IT sample sizes (N = 90 and N = 60, respectively) using
in children, and its potential to comfort and calm the power analysis.
HIV-infected child has yet to be explored. More recently, investigators have explored the
effectiveness of "17"in reducing state anxiety in diverse
Background populations, including the highly stressed Hurricane
Hugo survivors (Olson, Sneed, Bonadonna, Ratliff, &
Dolores Krieger (1979), introduced TI" to the nurs- Dias, 1992); a healthy sample of adults experiencing
ing community in 1971. Her research questions cen- an episodic stressful event, that is, students taking
tered on the idea that healing is a natural human poten- examinations (Olson & Sneed, 1994); and adult
tial that can be taught. She postulates hypothetically (Gagne & Toye, 1994) and adolescent psychiatric in-
that two factors are primary in the practice of TI': the patients (Hughes, Meize-Grochowski, & Harris,
focused intention to heal and a transfer of energy from 1996). Data gathered in these studies are consistent
environment, through the toucher, to and through the with that of previous studies, documenting that per-
subject. To date, this energy field has not been identi- ceived anxiety seems to decrease following "IT.
fied and the energy hypotheses not tested directly. Of the few extant studies that examined "1"1"as an
TT, then, is an intentionally directed process of intervention with children, none have focused exclu-
energy modulation during which the practitioner uses sively on the school-age child. Kramer (1990) exam-
the hands as a focus to facilitate healing (Mulloney et ined the effects of TT on the stress response of 30 hos-
al., 1996). It is an intervention that is passive in nature; pitalized children 2 weeks to 2 years of age. After she
it does not require that the client consciously partici- assigned children to one of two groups, "17" or casual
pate. The technique involves simultaneously centering touch, baseline pulse, peripheral skin temperature, and
awareness, directing compassionate intention, and galvanic skin response were measured "at the time the
modulating the flow of human energy through the use child was noted to be in stress" (p. 484). Significant
of the hands. It may include physical contact, but it is differences in the stress response in the TT group was
70 JANAC Vol.9, No. 4, July/August1998

found at 3 minutes and 6 minutes. Had Kramer Methods

reported random group assignment, the number of
children per group, and what constituted stress behav- Participants, Setting, Recruitment,
ior, her findings would have been strengthened. and Sampling Procedure
In a descriptive study of the healthy child's experi-
ence of receiving TF, France (1991) suggested that This was a convenience sample of 20 HIV-infected
children respond to "Iq" in ways similar to the adult. children 6 to 12 years of age--the age range in which
Before and after four to six T1~treatments, she asked A-state anxiety of the State-Trait Anxiety Inventory
11 participating children, (ages 3-9 years) to draw a for Children (STAIC) (Spielberger, 1973) is evalu-
picture of how they felt and to talk about the drawing. able--living in a northeastern city that is an epicenter
Statements of how they felt after q'q"differed from pre- of pediatric HIV disease. Recruitment was conducted
treatment descriptions. Several children said that TF at two pediatric ambulatory care centers specializing
tickled, or was nice. One child stated, "I felt like air. It in HIV disease following institutional review board
was like static. I felt like static" (p. 80). approval. During clinic sessions, site intermediary
nurses at each center informed parents/guardians that
Purpose and Hypothesis the author and two research assistants (RAs) were con-
ducting a study about the use of a nursing intervention
called T]" with HIV-infected children. If the par-
The bulk of ~ studies have been directed toward ent/guardian and child agreed to talk with the RAs, the
Euro-American adults, with no examination of this RAs showed them sample pictures from the screening
intervention with African American and Latino chil- tool; the Peabody Picture Vocabulary Test-Revised
dren, the disproportionatley affected and largest group (PPVT-R) (Dunn & Dunn, 1981); sample STAIC;
of children who have HIV infection. In addition, A-State Anxiety scale questions; and consent, assent,
although standard treatments such as neuroleptics and and demographic data forms. The consent form
group therapy are reported to help these children cope explained that a child would be randomized to either
with their distress and relieve anxiety (Pollack & T1~ or a sham treatment called mimic T'l', and briefly
Thompson, 1995), little systematically collected data described the two treatments. Randomization was
exists about psychotherapeutic intervention outcomes described as the flip of a coin; heads up, a child is
in this population. The current study responded to placed in one treatment; heads down, a child is placed
these research gaps. The immediate aim of this study in the other treatment. The RAs advised the par-
was to test the hypothesis that there would be a greater ent/guardian that they and their child would be told to
decrease in posttest state anxiety scores immediately which treatment the child had been randomized fol-
following treatment in children treated with q'l" than in lowing treatment. When signed consent was obtained,
children treated with mimic T'I'. Long-term goals are randomization was initiated. Only children who met
to develop methods by which stress-reduction tech- the criteria for selection--that is, age 6 to 12 years,
niques can be compared and tested for efficacy in English language dominant, no current psychotherapy
immunosuppressed children. nor psychotropic or anxiolytic medication, and an
Interventions designed to reduce the stress response age-appropriate score on the PPVT-R--were included
may affect the physiologic and emotional reactivity of in the study.
children with HIV disease. By quantifying the stress-
related response called anxiety, the investigator aimed Training and Orientation of the RAs
to demonstrate that T'I" is an untapped resource that
may help ameliorate or modify the experience of living Prior to data collection, the researcher introduced
with a chronic, yet life-threatening illness. If effective, the RAs to staff in each center, reviewed the issues of
TT could ultimately help these children in their search disclosure and stigma, reinforced the importance of
for normalcy and improve their quality of life. preserving anonymity and confidentiality, trained
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 71

them in the administration and scoring of the PPVT-R At the end of the session, the parent/guardian and
and STAIC, and instructed the mimic T r RA in that child were informed as to which arm of the study the
technique. The hand and body movements of the child had been assigned. Children who failed to meet
mimic qT RA were observed by the TT nurse expert the age-appropriate PPVT-R score were thanked for
until they were deemed to adequately resemble those their participation and returned to the parent/guardian,
used during TI'. without either being aware that the child had not met
A script was developed with the RAs to standardize the criteria for participation.
and keep verbal interaction between the RAs and each
child to a minimum at the point of treatment. To estab- TT and Mimic TT Protocol
lish the fidelity of the interventions, the researcher lis-
tened to each RA read the script and then, observed the Quinn and Strelkauskas (1993) suggested that there
q~F clinician administer T r to the mimic RA and the might be a relationship between the frequent practice
mimic RA administer the sham treatment to the q'T cli- of Tl" and its effectiveness. In the current study, a nurse
nician. This was done so that the investigator could who has practiced TT for more than 9 years, adminis-
ensure that, to the naked eye, there would be no observ- ters it at least once a week in her practice, and has used
able difference in treatment application. The validity it with HIV-infected children administered "IT in the
of mimic TI' as a single-blind placebo control for TT manner in which it has been taught by Krieger (1979),
was previously established by Quinn (1982). and as specified in Quinn and Strelkauskas (1993).
Specifically, the nurse systematically (a) centered her-
Data Collection Procedures self by shifting awareness from an external to an inter-
nal focus, becoming relaxed and calm; (b) made the
The two RAs visited the clinics once weekly, Janu- intention mentally to therapeutically assist the child;
ary 1997 through September 1997. Once informed (c) moved her hands over the body of the child from
consent was obtained, each child received the treat- head to foot, attuning to the condition of the child by
ment to which he or she had been randomized, follow- becoming aware of changes in sensory cues in her
ing physician examination and/or treatment. The des- hands; (d) redirected areas of accumulated tension in
ignated RA (either TF or mimic TF) took the child to a the child's energy field by movement of her hands;
quiet room and established rapport by introducing her- (e) focused attention on the specific direction of ener-
self again and reading an assent form with the child. If gies to the child, using her hands as focal points; and
a child asked that a parent be present, this was permit- (f) directed energy by placing the hands 4 to 6 inches
ted. The RA, however, explained that neither the child from the child's body, one just below the waist and one
nor parent could talk during the treatment session. behind the back. Total treatment time lasted from 5 to
After signed assent was obtained, the PPVT-R was 7 clocked minutes.
administered. If a child scored in the age-appropriate Mimic TI" is an intervention designed by Quinn
range on the PPVT-R, the RA asked the child to state (1982) as a single-blind q'F placebo to control for the
how he or she felt and recorded the response, asked the fact that a treatment is being offered and, thus, the sub-
child to read the instructions for the A-State Anxiety ject may expect relief. In this study, a TF-na'l've, fourth
scale along with her, and asked the child to fill in the year baccalaureate nursing student provided mimic
questionnaire. Questions were answered, and the child q'T. Quinn (1989) suggested that persons not experi-
was allowed to complete the questionnaire at his or her enced with "IF are the best candidates to administer
own pace. These tasks accomplished, the RA read the mimic q'I'.
standardized script and administered the treatment. Systematically following this sequence within a
When the treatment was completed, the anxiety scale clocked 5-minute time frame, the student RA (a) made
was readministered and the child was asked to say how the intention to imitate the movement ofTF; (b) focused
he or she felt, and these responses were recorded. Most her attention on mentally subtracting from 100 by 7s;
children completed the scale pre- and posttest in (c) moved her hands over the body of the child from
approximately 5 minutes. head to foot while continuing to subtract from 100 by
72 JANAC Vol.9, No. 4, July/August1998

7s; (d) retumed to the child's head and repeated step c; the child's feelings at a particular moment. Each
(e) placed her hands 4 to 6 inches from the child's response receives a weighted score from 1 to 3, with 3
body, one in the area in the solar plexus and the other representing the highest level of anxiety. Administra-
behind the child's back, and counted backwards from tion takes 8 to 12 minutes.
240; and (f) removed her hands when she had counted Spielberger (1973) reported Cronbach alpha coeffi-
down to 0 (Quinn, 1984, 1989). cients of .78 for males and .81 for females for the
Each treatment was given while a child sat sideways A-State scale. Papay and Hedl (1978) reported high
on a chair, so that the back of the chair did not interfere A-state internal consistency estimates for Black,
with access to the front and back of the torso and with inner-city fourth-grade males (.82) and females (.80),
his or her feet flat on the floor. They were instructed and moderately high estimates for the third-grade
not to talk during the sessions unless discomfort was males (.76) and females (.73).
experienced. The experimental and control condition The validity of the A-State scale has been estab-
were administered by separate RAs who administered lished in children with anxiety disorders, ages 5 to 17
their intervention to no more than 2 children during a (Strauss, Last, Hersen, & Kazdin, 1988); urban and
clinic session. suburban, low to middle socioeconomic status, bilin-
gual (Spanish and English), and monolingual children
Instruments 6 to 8 years of age (Murphy, 1990).

The PPVT-R, a widely used instrument in evaluat- Data Analysis

ing receptive vocabulary in children, was used to
determine a child's ability to understand instructions Analysis of covariance (ANCOVA) was conducted
and follow directions. The score reported as a measure to test the hypothesis that there would be a greater
of receptive vocabulary is a standard score equivalent, decrease in state anxiety scores immediately following
or PPVT-R IQ. An examiner presents a series of plates treatment in children treated with "IT than in children
with four drawings per plate, says a word, and asks a treated with mimic TI'. Correlated t tests were con-
child to point to the picture of the word that he or she ducted to gain further perspective on these relation-
has just said, and repeats this process until a child ships. Each child's open-ended responses before and
reaches his or her critical range (those items that pro- after treatment were reviewed to obtain a qualitative
vide maximum discrimination among persons of simi- perspective on the effect of T r versus mimic Tr.
lar ability). Administration takes approximately 10 to
15 minutes. Results
.,Split-half reliabilities for the L form that was used
in this study range from .67 to .88, test-retest coeffi- Of the 39 children recruited, 19 could not partici-
cients for raw scores from .73 to .91, and standard pate for the following reasons: (a) 5 were in foster care,
scores from .71 to .89 (McCallum, 1985). and the agency did not permit the guardian to sign con-
The PPVT-R has been established as a valid tool for sent; (b) 3 were taking psychotropic medication; (c) 2
African American and Latino preschool and school- failed to score in the age-appropriate range of the
age children with AIDS (Ireland, 1994; Levenson, PPVT-R; (d) 2 did not wish to participate; (e) 4 could
Kairam, Bartnett, & Mellins, 1991) and for healthy not stay to participate; and (f) 3 parents would not con-
African American and Latino preschoolers (Ireland, sent for the child to participate. As seen in Table 1, the
1994). majority of the 20 participating children were female
The STAIC (Spielberger, 1973), which was used to (65%), African American (50%), and asymptomatic
measure state-anxiety pre- and postintervention in (70%).
each group, is a paper-and-pencil, self-report inven- As noted in Table 2, most of the caretakers who
tory that is a downward extension of the adult STAI completed the demographic data form were mothers
(Spielberger et al., 1970). The A-State scale is com- (65%). Of these, 10 were biological, 2 foster, and 1
posed of 20 "I feel" sentence stems, designed to assess adoptive. Only 2 caretakers were biological fathers
Ireland / Therapeutic Touch With HIV-Infected Children 73

Table 1. Child Participant Characteristics (N = 20) Table 3. Pretest and Posttest Anxiety Mean Scores and
Standard Deviations By Group Membership
Child Data Number Percentage
Age Group Mean SD
6to9 10 50 Experimental ('IT)
10 to 12 10 50 Pretest 29.20 3.04
Gender Posttest 26.70 4.42
Male 07 35 Difference 2.50 2.46
Female 13 65 Control (mimic TF)
Ethnicity Pretest 31.20 4.51
African American 10 50 Posttest 29.50 3.37
Hispanic 05 25 Difference 1.70 3.91
White 03 15
Other 02 l0
Yes 14 70 (10%). Of the 25% who comprised the "other" cate-
No 06 30
gory, 2 were grandmothers, and 3 were aunts. More
that one half of the caretakers had not completed high
school (55%), and the majority (85%) were unem-
Table 2. Caretaker Characteristics (N = 20) ployed. Although 65% of them indicated that they
Caretaker Data Number Percentage were not themselves HIV positive, 14 reported that
one or more immediate family m e m b e r s were
Mother 13 65 infected. M o s t (85%) reported that they were
Father 02 10 religious.
Other 05 25 Pretest and posttest means on state anxiety for both
Education groups are presented in Table 3. A comparison of pre-
High school diploma
Yes 08 40 test means between the T r group (M = 29.2, S D = 3.0)
No 11 55 and the mimic T r group (M = 31.2, S D = 4.5) detected
Beyond high school 01 05 no statistically significant differences in anxiety, sug-
Employment status gesting that randomization resulted in groups compa-
Employed full time 01 05
rable in anxiety prior to the intervention. An ANCOVA
Employed part time 02 10
Unemployed 17 85 was conducted, examining the influence of group
Family income assignment on postintervention anxiety scores, with
Less than $5000 04 20 pretest scores included as a covariate. The resulting equa-
$5100 to $9000 03 15 tion was not statistically significant, F(1, 17) = 1.067,
$10000 to $19000 06 30
$20000 to $30000 05 25 p = .32. The inability to detect group effects in this
$31000 to $50000 02 10 analysis may be due to inadequate power given the low
Greater than $50000 00 00 sample size (N = 20). To gain further perspective on
HIV status this possibility, correlated groups t tests were con-
Positive 07 35
ducted within the T r and mimic T r groups to assess
Negative 13 65
Seropositive immediate differences in mean pre- and posttest scores. These
family members analyses revealed a statistically significant decrement
None 05 25 in anxiety posttest in the experimental (p < .01) but not
1 06 30 the control group (p = .20).
2 07 35
3 02 10 Analysis of the verbal responses by the children
Religiosity prior to and after experimental and control conditions
Not at all 03 15 demonstrated a variety of feelings and moods as noted
A little 10 50 in Table 4.
A lot 07 35
74 JANAC Vol.9, No. 4, July/August 1998

of the mean difference in the experimental group, 2.5,

Table 4. Analysis of Verbal Responses Before and After
however, was considerably lower than that reported by
either Heidt (1981) or Quinn (1984), who found mean
Group Before Frequency After Frequency decreases in state anxiety in their adult samples of 6.9
Experimental (TI') and 6.7, respectively. This could be explained by the
calm 2 calm 1 fact that pre treatment, their subjects were more anx-
happy 4 happy 2
fine 3 fine 1 ious with mean scores ranging from 36 to 38, whereas,
nervous 1 laughing 1 the current sample of children did not have mean
okay 1 good 4 scores greater than 32.
no comment 1 Examination of verbal responses to the question of
Control (mimic T'F)
good 1 good 1 how they felt prior to interventions suggests that this
great 1 great 1 was not an especially anxious sample of children.
happy 2 uncertain 1 These findings are consistent with those of Bose,
relaxed 1 dizzy 1 Moss, Brouwers, Pizzo, and Lotion (1994) in their
fine 3 fine 3 study of school-age children with HIV infection.
okay 1 okay 2
mad 1 weird 1 Although they studied primarily transfusion-infected
children living in middle-class families, those children
saw themselves as less anxious than respective stan-
dardization samples. If the stress that HIV-infected
Discussion children experience is as severe as assumed, then the
children in the current sample should have obtained
Recruitment and enrollment of 20 participants took scores reflecting more anxiety than they did. Some
6 months, reflecting the labor-intensive efforts required explanation is needed to resolve this apparent
in recruiting vulnerable populations with multiple incongruence.
demands on their precious time. Despite the aid of site As in the case of childhood cancer, lower than
intermediary nurses, data gathering was slow. anticipated scores on standardized measures of psy-
Research participation by some parents and chil- chological variables can be interpreted in several
dren was complicated by facts beyond their control: ways: (a) Resilience, coping skills, and support may
(a) Some children lived in foster care, necessitating lessen anxiety; (b) symptoms of anxiety may be denied
consent procedures that would have further extended (Kazak & Christakis, 1996); (c) children may act as
the data collection period, (b) other children had HIV- stoic good soldiers minimizing the severity of their
related cognitive deficits that precluded them from self-report symptoms (Kaplan, Busner, Weinhold, &
scoring in the age-appropriate range on the PPVT-R, Lenon, 1987); and (d) methodological difficulties of
indicating little likelihood that they would be able to self-report scales may preclude obtaining accurate
follow directions or read the STAIC questions, and data (Kazak & Christakis, 1996). In reference to the
(c) several children took psychotropic medications first interpretation, anxious symptoms that might be
that could have confounded data interpretation. found in this population may be ameliorated by the
Although we did not probe parents nor children increased attention and solicitude that parents and
who did not wish to participate, we were sensitive to health care providers offer them. For many, health care
the fact that this population had participated in other visits provide opportunities for stroking and praise
clinical trials, and may have been experiencing from nurses and physicians very committed to the
fatigue. Others may have had a healthy skepticism well-being of their clients. Indeed, the research team
about research and its potential to improve the child's was impressed with the depth of the compassionate
quality of life. care delivered by both, the parents/guardians and the
Among those who did participate, results suggested health care team, during the data collection period.
that "IT may be an effective tool for reducing state The level of awareness about having HIV infection
anxiety in children with HIV infection. The magnitude is unknown for this sample. However, many infected
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 75

school-age children are aware that they have the HIV Finally, whereas this sample was not staged accord-
virus (Wiener, Moss, Davidson, & Fair, 1992). Despite ing to disease severity as determined by C D 4 % - - a
this knowledge, they tend to seek normalcy. Thus, the marker of disease progression--this was a generally
only time they may think about their illness and con- healthy group of children; 70% were reported by the
sider that they are sick may be during illness events. parent/guardian as asymptomatic. Bose et al. (1994)
Meanwhile, they may make effective use of defenses found that low CD4% was one of the variables that
such as denial, try to live their lives as children, play contributed to the presence of adjustment problems in
with friends, go to school, and change and grow in HIV-infected children. That is, the lower the CD4 lym-
age-appropriate ways. On the other hand, some may phocyte count, the greater the disease severity. The
minimize the severity of their self-reported anxiety in greater the disease severity, the more likely it is that the
an effort to reduce complaining. There is a subtle child is exposed to stressors such as invasive medical
demand expectation in the social environments of procedures, opportunistic infection, and debilitating
some HIV-infected children to minimize complaining. illness, all of which may effect the child's psychologi-
Those children who know their diagnosis, or who are cal state.
at least suspicious that something is wrong, seriously
wrong with them, are aware that talking about their
concerns often raises parental/guardian anxiety. The current pilot study suggests that there is reason
Although not explicitly verbalized, those children who to pursue further research on the relationship between
live with their biological parents often recognize that TT and state anxiety among children with HIV infec-
illness discussion compounds parental shame over tion, and it supports a body of evidence that this tech-
having HIV themselves and that mentioning their ill- nique may help ameliorate or modify the experience of
ness tends to call this shame to mind, and may even those living with a chronic yet life-threatening illness.
confront parents with their own illness and potential TT may be at least as effective as other relaxation
death. When children live in foster or adopted families, therapies as a clinical strategy. However, the current
they may not easily disclose their anxiety because they study is merely a beginning to the work that needs to be
understand that the parent does not want to acknowl- done in psychosocial research related to care of chil-
edge that they know about their disease. Some parents dren with HIV infection. Given that the majority of
equate knowledge as harmful, fearing that knowledge studies about their emotional needs are not empirical,
of HIV infection can do physical harm, for example, and that there is a paucity of literature identifying
"If my child knows, he will die." interventions appropriate to those needs, "nurses 'do,'
In the current sample of children, anecdotal com- using interventions based on research findings of other
ments made by children, parents, and RAs following chronic childhood illnesses" (Sherwen & Storm,
treatment suggest that there was some denial and a 1996, p. 166). Well-designed intervention research is
covering over of concerns. For example, one child vital to establishing appropriate care delivery and
asked whether the treatment could bring a mother back improving the quality of life for the HIV-infected
from the dead or could help in communicating with a child. Directions for future research should include the
dead person. Another child was described by the RA as following:
emotionally "shut down," and one parent reported that
her child had low self-esteem. . measurement of the effect of stressors on anxiety
Self-report scales have the limitation in that they levels, both state and trait, and other psychologi-
reveal self-perceptions that are sometimes inflated and cal variables, such as mood, with a larger sample;
inaccurate. It might have been illuminating to have . clinical trials that compare the efficacy of TT
also tested trait anxiety, the more enduring aspect of with other complementary modalities and nur-
anxiety, rather than merely assessing state anxiety, a turing forms of touch, for example, the "nursing
more ephemeral reaction to a transitory event such as a back rub"/massage therapy (MT), in modifying
nursing intervention. anxiety and mood;
76 JANAC Vol. 9, No. 4, July/August 1998

3. longitudinal studies that allow for serial data col- Connor, E., Sperling, R., Gelber, R., Kiselev, E, Scott, G., O'Sulli-
lection points to extend knowledge about the van, M., VanDyke, R., Mohammed, B., Shearer, W., Jacobson, M.
Jemenez, E., O'Neill, E., Bazin, B., Delfraissy, J., Culnane, M.,
effects of such interventions on psychological Coombs, R., Elkins, M., Moye, J., Stratton, P., & Balsley, J.
variables beyond a one-time administration or (1994). Reduction of maternal-infant transmission of human
dose; immunodeficiency virus type I with zidovudine treatment. New
4 investigations that evaluate the potential of nurs- England Journal of Medicine, 331(11), 1173-1180.
ing techniques such as TI" and MT to influence Dunn, L. M., & Dunn, L. M. (1981). Peabody picture vocabulary
test-revised. Minnesota: American Guidance Service.
immunosuppression as has been done with other
France, N. E. (1991). A phenomenological inquiry on the child's
forms of stress reduction, for example, progres- lived experience of perceiving the human energy field using
sive muscle relaxation, in HIV-infected adults; therapeutic touch. Dissertation Abstracts International, 53,
and 3266. (University Microflms No. 92-15-316).
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atric Nursing, 8(3), 184-189.
psychological and physiological phenomenon, Gallagher, M. A., & Klima, C. (1996). The challenge of maternal-
thereby providing a biobehavioral framework in infant transmission of HIV. JANAC, 7(1), 47-48.
which to examine the influence of anxiety, Garrard, C. T. (1995). The effect of therapeutic touch on stress
depression, pain, and stressful situations on the reduction and immune function in persons with AIDS. Unpub-
child's immune system, and the effect of relaxa- lished doctoral dissertation, University of Alabama,
tion therapies on these phenomenon.
Grubman, S., Gross, E., Lerner-Weiss, N., Hernandez, M.,
McSherry, G. D., Hoyt, L., Boland, M., & Oleske, J. M. (1995).
In conclusion, a PNI framework could provide a Older children and adolescents living with perinatally acquired
holistic paradigm in which to launch future research, human immunodeficiency virus infection. Pediatrics, 95(5),
one that is consistent with the philosophical underpin-
Heidt, P. (1981). Effect of therapeutic touch on anxiety level of
nings of nursing science and one that could help hospitalized patients. Nursing Research, 30, 32-37.
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Acknowledgments. This research was supported Holistic Nursing, 14(1), 6-23.
by the Rutgers College of Nursing Center for Health Ireland, M. (1994). Death anxiety and se.lf-esteem in children four,
five and six years of age: A comparison of minority children
Promotion Research, Rutgers University Research who have AIDS with minority children who are healthy. Unpub-
Council Alpha Tau Chapter, Sigma Theta Tan Interna- lished doctoral dissertation, New York University, New York.
tional. The author thanks the staff, children, and fami- Kaplan, S., Busner, J., Weinhold, C., & Lenon, E (1987). Depres-
lies of Incarnation Children's Center of Catholic sive symptoms in children and adolescents with cancer. Journal
Home Bureau and Hew York Hospital-Cornell Medi- of the American Academy of Child and Adolescent Psychiatry,
26, 782-787.
cal Center Program for Children With AIDS who par-
Kazak, A. E., & Christakis, D. A. (1996). The intense stress of
ticipated in this study, and the research assistants, childhood cancer: A systems perspective. In C. R. Pfeffer (Ed.),
Lousia Porrata, RN, MPH, and Allison McClughan, Severe stress andmental disturbance in children (pp. 277-305).
who assisted with data collection. Washington, DC: American Psychiatric Press.
Kramer, N. A. (1990). Comparison of therapeutic touch and casual
touch in stress reduction of hospitalized children. Pediatric
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