INTRODUCTION

“The capacity to care is the thing that gives life its deepest meaning and

significance”

-Pablo Casals

Wisdom is the product of brain. Man has relied wisdom and development of

language to achieve his current state of dominance in the world. Intelligence is

clearly a salient feature in permitting the species to adapt to a wide range of

differing environments. The people of restricted intelligence are at a disadvantage

in solving problems and coping with new complex situations 9.

Mental retardation is not a disease or single entity. It refers to a

developmental mental disability and that appears in children by birth or under the

age of 18years. In most of the cases, it persists throughout adulthood. It can be

defined as a level of intellectual functioning is well below average and results in

significant limitations in the person’s daily living skills. It exists when there is

significantly sub average general intellectual functioning with concurrent

deficits in adaptive behavior.2 Failure to achieve developmental milestones is

suggestive of mental retardation. These limitations will cause a child to learn and

develop more slowly than a typical child. They are likely to have trouble in the

school. They will learn, but it will take them longer. The causes for mental

retardation are many may be biological or environmental factors or interaction

between two. It includes heredity about 30%, prenatal illness and issues, childhood

illness and injuries, and environmental factors. In about 40% of cases, the cause of

mental retardation cannot be found 2.

The severities of mental retardation have been identified under four levels

based on their I.Q level.

Classification of mental retardation

Level of Retardation Intelligence Quotient (I.Q)

*Mild (Educable) 50-70

*Moderate (Trainable) 35-49

*Severe (Dependent Retarded) 20-34

*Profound (Life support) Below 20

As the behavior and abilities associated with each of these levels are

different therefore care also should give accordingly; that is mild cases needs mere

guidance rather than physical care but profound cases depends on another person

for their routine care. 2

Mental retardation is a challenge not only to any nation, but also to the entire

human race. All over the world 83 million people are mentally retarded.

Prevalence of mental retardation is believed to be between 1% and 3%, with mild

retardation being most prevalent. Prevention is better than cure. Mental retardation

can be prevented by immunization against disease such as measles and Hib

prevents many of the illnesses that can cause mental retardation. Pregnant women

should be educated about the risks of alcohol consumption and need to maintain

good nutrition during pregnancy. Children should undergo routine developmental

screening as part of their pediatric care. Parenting a child with a disability is above

and beyond that of caring of a normal typical child but good parental care also will

prevent retardation. Mothers are the first teachers and children spend maximum

time at home, so mothers needs to be involved in training of mentally retarded

child in learning self care comprising of brushing, bathing, feeding , toileting,

dressing and grooming22.

Since mental retardation is common developmental problem among

children. Further, the investigator during practice in the school and community

observed that most of the parents have misconceptions and have lack of knowledge

about the care of mental retarded children and also number of study reported that

there is a lack of knowledge among the mothers regarding care of mentally

retarded children. It is very much important for nurses to assess and focus on each

mother regarding how they have to care their mentally retarded children. As a

nurse and researcher I have a vital role in recognizing problems of mental

retardation care and giving health education to mothers to improve the quality of

life3.

Play is the key centre of a healthy child’s life. Play provides the

opportunities to be free, creative and expressive. In play children expand their

understanding of themselves and others, their ability to communicate with peers

and adults. Play is the business of the childhood, allowing your child free rein to

experiment with the world around him and the emotional world inside him, says

Linda Acredolo professor of Psychology at the university of California. In play

children expand their understanding of themselves and others, their knowledge

of physical world and their ability to communicate with peers and adults. Play is

crusial for your child social, emotional, physical, cognitive growth.

Children under five years of age constitute the 15-20% of total population.

Morbidity rate among them is 35-65% of children population. In the history of

health services of many developing countries their social and health needs were

realized rather later. Now ministry of health in India has focuses attention to

provide better health services to this group because “A healthy child is a sure

future” is one of the themes of WHO. To make the child healthy quality child

care is needed. One of the important parts of child’s development is play.

It is often seems that all children do is play. They play until they are five

or six, then they go off to school and start to learn. They play until they are big

enough to really begins to do things. Play helps children to relax which makes

parents to relax4. “Play is a child’s work and this is not a trivial pursuit”, says

Alfored Adler. Play is synonyms with being a child and it is the universal

language of children. Hospitalization to any child is very unpleasant and

traumatic experience. The child undergoes break from his normal routine due to

illness but also separated from his peer group and friends3.

Essential child care needs play therapy should be included with medical

therapy in hospitals. Mothers should be enhanced to provide play needs during

hospitalization to lessen the emotions.

NEED FOR THE STUDY

“Mother should teach children what is best for them.

She directs children in the way they should go”.

-Bible

God’s greatest gift to man is the ability to perceive the universe in all

contrasts. Brain is the vital gate way of perceiving the world. The brain is highest

nerve centre of nervous system. Brain is not only receptive but also expressive. For

example, when brain perceive a problem, brain itself gives a solution what has to

be done to overcome from that problem. Emotions and personality of individuals

will develop based upon how he perceive, think and judge. Mean while brain if not

developed properly it leads wrong pathway or the way may not be clear 4.

In every country mothers and children constitute a major segment of the

total population therefore service to children since womb is very much

important and tremendously significant in health care delivery system. Every

parent wants their child to be well behaved and encouraging focus and self

discipline is an important issue both at home and at school. But when a child has

mental retardation, they will neglect and abuse their children in comparison with

their non disabled children. Parents are stressed and worried due to care of their

defective child 15.

A cross sectional and descriptive study was conducted to find out the

refractive error among the students in the Nepal at school for mentally retarded

children. Estimated the prevalence of mental retardation in Nepal is 4.1%. A total

of 140 clinically diagnosed cases of mentally retarded students from three different

schools of Kathmandu Valley were examined. Examination revealed that more

than half of the examined had one or more ocular disorders with refractive error

being the most common type of ocular morbidity followed by ocular disorders.

Refractive error were found in 34.4%.Vision being the best sense for their

education and daily activities 6.

It is said in developing countries Down syndrome is very common cause for

mental retardation in children and it is estimated that in India there may be more

than one million children are suffering with mental retardation. Consanguine

marriage is the major cause for mental retardation in southern States like Andhra

Pradesh, Karnataka, Tamil Nadu, Kerala. People believe that, marriage should do

within the relation then children will be healthy and property also will not go out of

the family. Therefore pre marriage counseling is very much important 14.

A study was conducted on 934 mental retarded children in selected cities of

Perth in Australia to assess the prevalence of mental retardation and found that

79% of children suffering with mild mental retardation, 12% of children having

with moderate type of mental retardation and about 9% of children suffering with

severe type of mental retardation 8,10.

As many as 3 out of every 100 people in the country have mental retardation

(Arc.2001) nearly 6,13,000 children aged 6-21 year have some level of mental

retardation and need special education in school(annual vs. report 2002) in fact 1

out of every 10 children who need special education has some form of mental

retardation. About 87% of people with mental retardation will only be a little

slower than average in learning new information and skills. The remaining 13% of

people with mental retardation scores below 50 on I.Q. test. These people will have

more difficulty in school, at home and in community 12.

A study conducted on assessment of parental needs regarding care of their

mentally handicapped child at NIMH in Secunderabad. Research indicated that

76.6% of parents have expressed the need for seeking information regarding

therapeutic, educational, and vocational programs. Parents were interested to

know more about training in communication, management of behavioral

problems and training in Self-help area13.

With the evident of de-institutionalizing and mainstreaming, the role of

parents in the care and management of their MR children has gained prime

importance. In recent years all over the world, there has been a movement away

from institutional care and is towards home-based care of individuals with mental

retardation. The National policy on mental handicap (1999) has emphasized the

importance of home -based care with parents as parents in the care process 13.

A research project conducted on ‘home - based care programs for parents of

children with intellectual disabilities’ at school of occupation and leisure

sciences, University of Sydney. The sample for the study was randomly chosen

parents (n=45) of mentally retarded children of under four years age. Results

indicated that parental education in home - based care is effective in making

the parents to be efficient in training their mentally retarded child to be

independent in their self-help skills.

A study conducted on needs expressed by mothers and fathers of young

children with handicaps in UK. On 100 parents of developmental disabled

children. Study revealed that 80% parents were demands for training in

communication, management of behavior problems and training in home-based

care of the MR children. About 1.8 percent of mothers knows proper care of

mental retarded children; approximately 12 millions are having deficient

knowledge about care of mental retardation. It evidence that cumulative

exposure to highly responsive parenting styles through out the early childhood

period may provide variety of important child benefits in terms of language,

cognitive, social, emotional development. Maternal responsibility as a dynamic

construct of central importance to the development of children with intellectual

disabilities just as it is for typically developing children.

An expert explained how to care the mentally handicap children by their

parents with good example, you have dream to go for Italy and got a chance to go

there so u prepared well and started journey but ultimately the plane will drop you

in Holland due to some reason. And you meet people came back from Italy will

praise and explain the beauty of Italy then you feel gilt because you have missed a

chance to go there mean while you will miss the enjoyments of Holland. Therefore

instead of thinking bad fate we should enjoy the present. Likewise, children are

always children only so you should have a mentality to care and enjoy properly.

Since mental retardation is a developmental problem among children. It is

evident that mental retardation can be preventable and manageable. This calls for a

more concentrated effort on the part of medical profession and those engaged in

child care activities. As a nurse and researcher I have significant role in

recognizing problems of mental retardation care and giving health education for

mothers to improve knowledge and practice of mothers regarding care of preschool

mental retarded children.

Malnutrition is the major cause of death among children in India. According Dr.

B.M. Chauhan (1981), the magnitude of the problem is that every one lakh

children die either directly or indirectly attributable malnutrition. The ICDS

programme acknowledged that young child is most vulnerable to malnutrition,

which leads to morbidity and mortality of children under six years. This program

helps to promote holistic development of children under six years through

Anganwadi at the community level.3

The Anganwadi worker in ICDS programme assumes a pivotal role in

Anganwadi centre due to her close and continuous contact with the community.

By virtue of her position in the community, the Anganwadi worker has more

chances to interact and to educate the mothers. For that the Anganwadi worker

should have basic knowledge of child care activities. The functions/activities of

the Anganwadi worker are :

1) Community survey and enlisting beneficiaries

2) Organize supplementary feeding

3) Growth monitoring

4) Primary health care and First –Aid

5) Non formal Pre-School Education of the children between 3-6 years of age.

6) Assisting the health staff in immunization, distribution of Vit. ‘A’ and Iron

& Folic Acid and health check up.

7) Referral Services

8) Health and nutrition education of pregnant and nursing mothers as well as

mothers of the children.

9) Maintaining liaison with other institution and organizing and conducting

functional literacy.

Among all these functions growth monitoring and supplementary feeding

are directly linked with the prevention and control of malnutrition in children. And

also these two activities are independent activities carried out by the Anganwadi

worker in relation to promotion of health of the children.

The studies also revealed that there is a need to strengthen the Anganwadi

worker in these areas.

Study conducted by on growth monitoring revealed that several Anganwadi

workers are not taking precautions while measuring weights of the children and

they are not informing the progress of the child to the mothers.4

Study conducted revealed that several Anganwadi workers are not following

the norms laid down for enrolling the beneficiaries and they are also providing

supplement to all children equally, irrespective of their age, nutritional grade and

served twice to the children who wanted more. Another study in 1992 stated that

there is a need to improve the skills in growth monitoring and supplementary

feeding and recommended short-term feeding and frequent in-service training

programmes to the Anganwadi Workers.

As the investigator observed that the Anganwadi Workers are not having

adequate knowledge in performing their set functions specially with emphasise to

growth, monitoring and supplementary nutrition. The Anganwadi workers also are

not following principles while checking growth monitoring and distribution of

supplementary food. The investigator also found that there is no study related to

knowledge and practices of Anganwadi workers in Bangalore rural Anganwadi

Centres.

The investigator felt that the Anganwadi worker should be self sufficient to

deliver these activities in prevention and control of malnutrition among children at

grass root level by providing services at doorstep.

The investigator found that the Anganwadi worker not only identify the

malnourished children but also children at risk for malnutrition through growth

monitoring and supplementary feeding. Since these two activities takes major

contribution in maintaining the health of the children, the investigator taken these

two activities in the study in a limited time.5

Health care of children has been markedly changed in

developed countries. There is a change in the view of children from,

“miniature adults”, to “unique individuals” with special needs and

qualities.

The child care has prime importance, as the mortality and

morbidity are higher in this group. In India the mortality rate under five is

105 per 1000, while in Japan it is 6 per 1000.(W.H.O.2003) This can be

reduced by demonstration, health education and guidance to the parents

and creating awareness and making changes towards the health care

branches.

Play is a very important component of children’s life. It is the

most essential activities for the physical emotional and social

development to the child.

It has special importance in the hospital to help sick children to continue

to grow and develop, to preserve their sense of wholeness to understand

hospital procedures, and to act out emotions. The separation of the family

during hospitalization cause an anxiety in the young children and may

disturb parent child relationship.

Beryl Julliet Sam(2007). Assistant Professor Child health nursing

department Coimbatore, Tamil Nadu conducted case study to assess the

knowledge attitude and practice of the parents and nursing personnel

regarding importance of play needs in hospitalized children. He assessed

that 86.11% of nursing personnel had adequate knowledge, 13.89% had

moderate knowledge. But 94.44% of them shows favorable attitude

towards the importance of play during hospitalization6

There are now ample research to demonstrate that

hospitalization has considerable potential to cause long lasting emotional

damage(Vernon,1966 Douglas, 1975; Thomason 1986). A child most

often looks dull anxious, afraid or angry. Mothers feel that their children

become passive after the admission to the hospital7.

Bradshaw’s and Silva,1980,Thomson and Standford (1981), says we

know the experience of being in hospital is , itself , a major stress for

children which is additional to the stress of illness. More over he is

subjected to lot of interventions which are directed to the promotion of his

health but aggravate his pain and sufferings8.

Singer. J , (2000) conducted a case study on a play therapy on

Massachusettrs General Hospital, Boston. They found that parents have

knowledge of play for children. 74.98% of the parents knew the

importance of play for their child, but only 28.53% parents have favorable

attitude to provide during hospitalization to the children9.

Keyes, Marianne, NewZealand (1991) says in their studies-that all

children do play. Play is vital to life, it is child’s life. During

hospitalization child exploring and elevate the crisis of hospitalization by

play. Play also helps in speedy recovery. The recovery rate is more in

children who got play therapy during their hospitalization. Hospitalized

children require more than recreational play because illness and

hospitalization constitute crisis in child’s life. These situations are fraught

with over whelming stresses. Children need to play out their fear, angers

and anxieties as a means of coping with these stresses. Play also helps

temporarily to divert their mind from pain and loneliness. Mothers play a

major role in providing play to children because child feels secure and

confident in mother’s lap.

Dr. Harish chellani, Professor from Safdarjung hospital Delhi (2007)

spoke on the concept, Integrated Management of Neo-natal and

Childhood illness at training course organized by TNAI with

collaboration of Common Wealth Secretarial London, he stressed that the

health services should include play therapy with cure therapy for

children1.

Haiat H, Bar-Mor G, Shochat M,(1991) Dina Academic school of

Nursing says that the world of a child is a world of play even in the

hospital. Hospitalization to any child is very unpleasant and traumatic

experience. The child’s familiar routine are interpreted, they are

surrounded strange and often frightening people, equipment, sounds,

smells. Opportunity for play and exploration is severely curtailed or non

existent10.

` After investigation the research studies , review of literature

regarding importance of play in child’s life the investigator found the

need for study.

REVIEW OF LITRETURE

Review of literature is a summary of research on a topic of interest, often

prepared to put research problem in the context as the basis for an implementation

project (Polit & Hungler).

Review of literature explains the research and non research literature to

broaden the understanding and gain insight into the selected problem under study.

A review helps to lay the foundation for a study and can also inspire new research

ideas. The task of reviewing research literature involves the identification,

selection, critical analysis and written description of existing information on a

topic 2.

Review of literature refers to “an extensive, exhaustive and systemic

examination of publications relevant to the research project”. A very few studies

have been alone in the field of mothers regarding care of mental retardation. The

review of literature for the present 0study has been done from published articles,

journals, pub med and internet search on care of preschool mental retardation 11.

A survey was done to reveal the Impact of Cultural Beliefs and Practices on

Child Health among the Yoruba. Data were analyzed to determine 1) mothers

perceptions on etiology of childhood diseases and the effect of these beliefs on

which curative measures they suggested and 2) the persistence of the belief in

“abiku” (special children who have come from the spirit world and can die at will

unless certain rituals performed) and how the belief can influence the way of

mothers to manage childhood diseases. The data for this study, collected via

formal interviews with 1559 respondents supplemented by in-depth interviews and

focus group discussions, were submitted to simple cross tabulation and logistic

regression analysis. And found that 1) many of the mothers lack accurate

information about the causes of the selected childhood diseases, especially mental

retardation; 2) many of the mothers nevertheless recommended modern curative

methods; 3) the belief in abiku remains strong among these mothers; and 4) the

curative measures adopted by a mother may depend upon whether the sick child is

believed to an abiku. Over half of the mothers believed that an abiku required

treatment from traditional healers and religious institutions irrespective of the

nature of the illness. Thus, the probability of a child is perceived to be abiku. This

study underscores the need to consider local beliefs and practices when

implementing health policies 8, 10.

A cross-sectional descriptive survey was done in school of Washington to

determine how siblings are affected by having a brother or sister with

developmental disability. The study evidenced that, there is a negative effect on

sibling of child with mental retardation when compared with sibling of healthy

child. However, negative attitude towards defective child is decreasing

significantly in recent years because of changes in public attitude towards disabled.

A study had conducted in Middle Eastern Country to assess knowledge and

practices of parents. It reports, in many countries of Middle East including

Lebanon there is a stigma attached to families who have mental retarded child.

These families complain of isolation and lack of community resources that could

help them to cope with their circumstance to optimize the child’s abilities. Health

professionals and researchers should recognize factors related to the process of

stress adoption to help families and cope with their circumstances. The aim of this

cross sectional study was to identify factors that play a role in mothers with

adoption of the care for their intellectually impaired child. The results based on a

sample of 127 mothers from Lebanon reveal that, a high percentage of mothers had

depressive symptoms. The significant factor identified by this study was parents

have lack of knowledge regarding care of mental retarded children and they need

proper guidance 18.

A study was conducted in Kingston to assess the knowledge of mothers

regarding care of their intellectually defective child. In the study 226 mothers

from different cultural background were included. Assessment was done by using

formal questionnaire. Most of the mother had deficient knowledge on care of

defective child. Many of the mothers considered their defective child as a burden

and isolated in house. Had poor knowledge regarding self care, health problems,

and diet of mental retarded child. Report shows 15% of mothers had good

knowledge, 27% moderate, and 48% of the mothers had very poor knowledge

regarding care of defective child 15.

A survey was done in Hyderabad to assess knowledge of people about

causes and treatment of mental retardation in children. In society there is a

stigma about mental illness as well as mental retardation. People believe that

mental retardation is due to black magic, gods disgrace, or sins of ancestors. Even

educated people believe that no treatment for mental disorder. Half of the

population seek required treatment from traditional healers and religious

institutions irrespective of the nature of the illness; 20% of the people seek

medical treatment as well as religious care for mental illness; and Only 10% of

the people go to mental hospital. People believe that going to mental hospital will

reduces family dignity and have to face religious stress. Post natal mother will

keep semi starve for 3 months it cause nutritional deficiency intern leads to

mental retardation. Consanguineous marriage is most prominent cause for mental

retardation in South India 9.

A comparative study conducted to assess prevalence of mental retardation.

The data from the Metropolitan Atlanta Developmental Disabilities were used. The

administrative prevalence of mental retardation (I.Q of 70 or lower) was identified

by review of records from multiple sources, with the public schools as the primary

source. The overall administrative prevalence of mental retardation is 12.0 per

1000 children. The rate from mild m r (I.Q of 50-70) was 8.4 per 1000 and the rate

of sever m r (I.Q <50) was 3.6 per 1000. The prevalence was higher in Black

children than White children (prevalence odds ratio [POR] =2.7) and in boys than

in girls (POR=1.4). Children with severe mental retardation had more coexisting

disabilities than children with mild mental retardation. The mental retardation

prevalence rates reported here, especially the race-specific rates, may reflect social

and demographic feature unique to the metropolitan Atlanta area and therefore

should be used with caution in making comparisons with other populations 16.

A specific cause is identifiable in only about 25% of people who are

mentally retarded and of these only 10% have the potential for cure. In the

remaining 75%, predisposing factors, such as deficient pre natal care, inadequate

nutrition, poor social environment, and poor child-rearing practices, contribute

significantly to mental retardation. Mental retardation has no cure but we can

prevent before it develop or we can best manage with proper care 14.

A study on evaluation of an intervention system for parents of children with

intellectual disability and challenging behavior, among 115 families in Japan.

During educational program signpost material such as information booklets, a

workbook, videotape for parents and a series of educational programs were

delivered to the parents. On post-test 80% of the subjects reported that they felt

more efficacious about managing their child’s behavior and reported high levels of

satisfaction with the delivery of the material and educational programme 20.

The study was conducted on 95 families to assess the effectiveness of parent

skill teaching program regarding care of mentally retarded children. 20 week

behavioral training program had given to the parents with mental retarded children.

Feed back have done after 14 months. It shows that 855% of the parents had

retained their knowledge of programming principles. Carried out regular teaching

sessions and children retained their original of new skills; 10% of parents had

followed few principles of teaching sessions and children gained few new skills;

and <5% of parents did not follow any principles of teaching sessions and there is

no gain of a new skill in their children 19.

A study conducted regarding ‘involvement of parents in training mild

mentally retarded children in self care and play skills’ among 30 parents of

children between four to eight years of age in a rural area at Secunderabad in India.

Subjects were pre-tested and knowledge scores showed that 20% of the parents had

awareness about the item ‘home based care improves self care activity’. A training

program was conducted for eight weeks with the help of flash cards, books,

individual demonstration and videocassette of step-by step learning. Final

performance test was administered, percentages and paired’t’ test was applied to

test significant difference between pre test and post-test scores. Findings indicated

that 60% of the parents had improved awareness towards the same item. Post-test

scores were higher than pre-test scores with mean scores difference of 15.5 and‘t’

value 29.27,14.

The study conducted on parent’s practices regarding care of mental retarded

children. Most of the parents experience mixed and some time contradictory

feelings. They may feel left out new family development and changing roles guilt

and sad when their disabled child is unable to participate in activity or play game.

Even parents feel embarrassed and ashamed, having a mental retarded child in

family. Father Judge wrong about what future holds for their child as well as

his/her ability to manage the increasing financial burdens. Mothers experience

stress and guilt often while caring a defective child 16.

Dorthy R.Marlow says that the play helps the children to form concept,

classification, and contrast and compare relationship among objects, cause

effect relationship. Concept of time, object characteristics and problem

solving.

Garvey (1984) conducted a study regarding toys and plays and expressed

his ideas that play and play toys develop the ability to represent

experience symbolically. They expressed their ideas and feelings about

the social world around. King, 1986 said that children learn during play to

negotiate offensive alternatives and need for defense11.

Piaget (1962), Bergen (1988) states through their study that children

expand their understandings of themselves and others, their knowledge of

physical world and their ability to communicate with peers and adults. At

9 month infants learn that a ball rolls away, a rattle make noise. At 12

months objects bring forth more specific and differentiated actions. By the

age of 4 or 5, child’s ideas about the social word initiate most pretend

play. In Toddler, there is growing awareness. They share, communicate,

expresses anger or joy through play.

Caldwell,B.,(1977)conducted a case study on children under five in

kinder garden at Lucasa. He found that children under five shows their

aggression and hostility through play either throwing toys or snatching

toys form other children. He conducted the study on 20 children age 3-5

years, by giving them only one Barbie doll. 12 out 20 eagerly get up to

get, snatching and pushing each other for toy, but five remained sitting

silently ,three out of twenty not shown any interest, but they remain silent

and looking towards the others. It shows that toys attract the children.

They enjoy as a fun for them14.

B. Review of literature related to curtail of play and its effect on under five children during hospitalization.

Keys, Marianne, (1991) conducted a case study in New Zealand and

concluded that children requiring extensive hospitalization to understand

cope with their illness, treatment and hospital experiences. He conducted

a study on three children who have to stay long time in the hospital for

recurrent surgery. The children who participate in play programmes have

three to five years of age. One is 4 years old female who had congenital

problem who requires repeated surgery, the second a boy who need

correction of oesophageal atresia and the third is five years old boy who

had congenital cardiac anomalies. After 11 month, the author evaluated

the result. The four years girl who has attended play therapy during her

hospitalization regularly shows speedy recovery and healthy growth than

the others two who have not attended the play therapy. This shows that

play during hospitalization helps to cure faster than the others15.

A report published by American Academy of Pediatrics (9.10.06) the

importance of play in promoting healthy child development and

maintaining strong parent- child bonds-Mother play an important role

because the child feels more secure and confident in the presence of

mother. Play brings you closer to your child. It helps them to become

more independent. They more able to work problems out, to develop their

own concentration and imaginations7.

Vernon, (1966), Doglas, (1975) Quinton and Rutter, (1976), Golden,

(1983) and Thomson, (1986) did research on role of play in assisting

children requiring extensive hospitalization in Auckland Children’s

Hospital. They say that we know that the experience of being in hospital

is itself a major stress for children which are additional to stress of the

illness. Children respond to this stress in varies ways according their age,

personality emotional state and their previous experience in hospital, and

the attitude to those caring for them. Play is the best alternative to cope

with stresses16.

Barker (1974), Beuf (1979), Simons, Bradshaw and Silva(1980),

Thomson and Standford (1981) says that it is not surprising that

developmental regression is common and the emotional withdrawl may be

adapted as a way of shutting out experiences with which the child is ill

equipped to cope. Play therapy helps them to communicate with them and

cope with emotional hazards17.

Bergan D (1988) states in his study that play is an important part of the

care we provide to the children which allow them acknowledge and deal

with their illness and treatment through play. They keep children

occupied, they help them to cope with pain, anxiety and fear, to make

friends to regain skills they have last as a result of their illness and learn

new skills

C. REVIEW OF LITERATURE RELATED TO ATTITUDE AND

PRACTICE OF MOTHERS REGARDING PLAY NEEDS

DURING HOSPITALIZATION.

Rev Esc Enfern USP (1999Dec), 33(4):364-9. “Playing in hospital:

addition to nursing care”. Playing is one of the essential activities for

physical, emotional and social development to a child. The empiric data

collection realized through the participant observation of 11 children.

They identified that the act to play has repercussions into the child, nurse

and hospital; to the child it is not obstruct the development, helps it in the

understanding about what is occurring with itself. They discharge tension,

fear, anxiety and frustration, promote satisfaction, funny and spontaneity

and allow it transforms experiences that should support inactive in active

discharge. To the nurse it is tool of intervention and way of

communication. More necessary is to initiate the play. Mother can play a

vital role in it18.

Dorthy R.Marlow, says, the presence of an adult in the play of toddler

facilitates release of aggression, while helping expression impulses by

under control. Guidance should not inhibit self directed activity. It is

important for adults to provide material which children can explore and

adopt in the play.

ERIC # Journal Articles: Reports- Evaluation, “Use of Art of Play

therapy in oncology”. Two play therapies applied by parents for

darkness phobia in young children are compared. 27 children between the

ages of 4-6 years were recruited from 27 schools. The participants were

randomly assigned to three experimental conditions bibliotherapy and

games, emotive performance and no treatment. The treatments were

applied at home by parents who were trained previously and it last for 5

weeks and took place in three 20 minutes alternate weekly session. Both

therapy shows significant result. The study shows that art and play has

great effect on children under five. They can cope up with their problems

easily through play they become more understandable and confident19.

Calwell 1997) said that adults should identify play which has led to

problems for particular children. They should check materials, equipment

for safety. Adult should make children aware of any hidden risk in

physical challenges they set for themselves.

According to PMID:1340875 a child’s play is recognized as a useful tool

for nurses in the diagnostic process of making judgments about a

hospitalized child’s compliance with medical procedures, adjustments to

the hospitals, environment, degree of pain, and level of psychosocial

functioning. However, the bases that is required to effectively help a

pediatric patient “play” in a therapeutic mode appears to be extremely

limited for most nurses and is rarely addressed in a substantive manner in

nursing education. Educational programs must be willing to incorporate a

“developmentally appropriate, culturally sensitive, and family-centered

approach” using clinical experiences and professional role modes in their

nursing curricula. The end product should be nurses who are competent in

a much wider range of learn to play. They can take the help of mothers.

Nursing Clin North Am 1984 Jun,say that play for most hospitalized

children centers around self and stressful situations as perceived by the

child and is restricted in terms of what the environment and physical

limitations so the child present. Play can be a tool to understand and

intervene with pediatric patients. Collaboration with nurses who are

clinical specialists, early childhood educators, and others who have expert

knowledge of children and play equipment is useful to plan purposeful

play programs or programs or play sessions for the special need of

hospitalized children. Such collaboration will insure that play will be

carried out in consistent growth promoting manner. For some children,

hospitalization is an challenging experience that promotes a sense of

competence. For other children, hospitalization is an experience that

results in a negative outcome.

An American Association Nursing care of children and families,

(2000) describes that, “hospital play is an important part of medical care”

20. Play can really make a difference-

o Create an environment where stress and anxiety are reduced.

o Help the child to regain confidence and self esteem.

o Provide an outlet for feelings for anger and frustration.

o Help the child understand the treatment and illness through play.

o Aids in assessment and diagnosis.

o Speed recovery.

o Advance physical development.

o Promoted social skills.

o Build imagination.

Statement of problem

“A study to assess the effect of structured teaching programme on the

knowledge of care of mentally retarded children among the mothers who attend

selected special schools at Bangalore”.

6.3 Objectives of the study

To assess the level of knowledge on care of preschool mentally

retarded children among the mothers

To determine the effect of structured teaching programme on the

knowledge of care of preschool mentally retarded children among

mothers

To find out the association between level of knowledge and selected

demographic variables among mothers

Operational definitions

Assess

It refers to the statistical measurement of the knowledge and practice of

mothers regarding care of preschool mental retarded children.

Structured teaching program (STP)

Indicates to a material used for teaching which is prepared by researcher and

content validated by experts. It is intended to provide information or knowledge on

care of mentally retarded children.

Knowledge

It refers to the correct answers to the items in the questionnaire regarding

care of preschool mental retarded children.

Mothers

It refers to the mothers who have children with mental retardation in the

age group of 3 to 5 years

Mental Retardation

Mental retardation refers to significantly sub average general intellectual

functioning existing concurrently with deficits in adaptive and functional behavior

manifested during the developmental period.

Mentally Retarded Child

A child who is unable to perform his routine work independently due to his

retarded development of brain at the age between 3-5years.

Special School

A small unit adapted to serve primary needs of mentally retarded children it

forms the pillar upon and around which all activities.

Assumptions

It is assumed that

Mothers of preschool mental retarded children possess some knowledge and

practice regarding care of mental retarded children.

Selected demographic variables have influence on mother’s knowledge and

practice regarding care of mental retarded children.

The responses of the mothers of preschool mental retarded children to the

items in the structured interview schedule would reflect the true knowledge

and practices regarding care of mental retarded children.

METHODOLOGY

Source of data:

The source of data were primigravida mothers who were attending the

antenatal clinic at Hospital, Bareilly.

Methods of data collection:

Data was collected by the investigator her-self by using structured closed

ended questionnaire and check list. During this period investigator collected both

pre and post-test data and also implement the structured teaching programme.

Research design and approach:

Quasi-experimental design in which one group per and post-test design

without control group will be selected for the present study.

Setting:

The study was conducted at antenatal clinic in Manas Maternity Hospital at

Bareilly.

Population:

The population for the present study will be the primigravida mothers who

attending antenatal clinic in a Manas Maternity Hospital, Bareilly.

Sample size:

The sample size was 50 primigravida mothers.

Sampling technique:

Purposive sampling technique was used for the proposed study.

SAMPLING CRITERIA:

Inclusion criteria:

Primigravida mothers who are

- Attending the antenatal clinic Hospital, Bareilly.

- In 21 to 35 weeks of pregnancy.

- Able to read and understand Kannada and English.

- Willing to participate in the study.

- Available during data collection period.

- Not having labour pain.

Exclusion criteria:

Primigravida mothers who are

- Not attending the antenatal clinic in Manas Maternity Hospital, Bareilly.

- Not in 21 to 35 weeks of pregnancy.

- Not able to read and understand English.

- Not willing to participate in the study.

- Not available during data collection period.

- having labour pain.

Data collection tool

Three types of tools will be used. They are:

- Closed ended Questionnaire to assess the mother’s knowledge on antenatal

care.

- Check list to assess the mother’s practice on antenatal care.

- Structured teaching programme on antenatal care.

-

Period of data collection:

The data will be collected in the month of Feb/March 2015.

Data analysis method:

The collected data was organized, tabulated and analyzed by using

Descriptive statistics i.e, percentage, mean and standard deviation.

The inferential statistics was used for chi-square test and paired ‘t’ test.

The paired ‘t’ test was used to find out the differences in knowledge between

pre and post-test.

Chi-square was used to find out the association between demographic

variables with post-test knowledge scores.

The data was planned to be presented in the form of tables and figures.

STATISTICAL ANALYSIS

The data obtained will be analyzed in terms of objectives of the study by using

descriptive and inferential statistics. Frequency and percentage will be used for

analysis of demographic data of group. Mean, Median and Standard Deviation

will be used to assess knowledge and practice of primi antenatal mothers. A

Paired “t” test will be used to compare pretest knowledge and practice with post

test knowledge and practice for both groups. Co- relation co-efficient to find the

relationship between knowledge and practice of primi antenatal mother on

antenatal diet. A chi – square will be used to determine the association between

post test level of knowledge and practice score on antenatal diet with their selected

demographic variables.

DISCUSSION

The term malnutrition can be applied to any disorder that prevents an

individual from achieving optimal nutritional state. The cause of malnutrition are

poor feeding practices, and infection, particularly frequent or persistent diarrhoea,

pneumonia measles, and malaria and poor feeding practices ,such as inadequate

breast feeding offering the wrong foods, giving insufficient quantities,

Malnourished children are more vulnerable to disease and the improved feeding

practices to prevent or treat malnutrition could save 8, 00,000 lives/year7

Core health indicators of India from multiple WHO sources show that

children aged under five years stunted for age (%) rural and urban are 48.5 and

35.7, children aged under five years stunted for age (%) lowest and highest wealth

quintile are 58.1 and 26.7, and child aged under five years stunted for age (%)

lowest and highest educational level of mother are 54.9 and 30.6. Hence these

statistics shows that rural under five children are at high risk for malnutrition. So

mothers of preschool children should be educated on measures to improve

nutritional status of children8

A survey on global hunger index was conducted in year 2007 by

International Food policy Research Institute (IFPRI), Washington. The study was

conducted in 118 countries. The results shows that India ranks 94 th, China 47th,

Pakistan 88th and one in seven people go bed to hungry and 40% of the world’s

underweight children under five live in India the study indicates the need for

sharing information on prevention of malnutrition in children among mothers. 9

A case-control study was conducted by school of Epidemiology and Public

Health, Yale University USA in rural south India in 1997 on maternal knowledge

of malnutrition and health-care-seeking attitudes 34 cases and 34 controls were

selected from the population of approximately 97,000 and the results shows that

the two groups showed a significant difference in nutrition –related knowledge of

mild mixed malnutrition (OR=2.62,P=.05) the gender of child and socioeconomic

factors were stronger risk factors for malnutrition. These results suggested a need

for intensive nutritional programmes targeted toward poor female children and

their mothers 10

A descriptive study was conducted in Aligarh in 1991 to evaluate the role of

weaning in determining the nutritional status of infants as well as to identify the

socio-cultural factors affecting weaning practices in rural areas and results shows

that nutritional status was not associated with social class, inadequate knowledge

about proper weaning, not lack of food, was the limiting factor in infant nutrition.

Education about the importance of food, was the limiting factor in infant nutrition.

Education about the importance of proper weaning and weaning foods imparted by

grassroots level workers is needed11.

A historical study was conducted in India in the year 1985. The purpose was

to study nutritional histories of severely and moderately malnourished and

adequately nourished Indian preschool children within a homogenous community.

Maternal perceptions and ratings of regularity of food intake, types of weaning

foods, and the types of food eaten at breakfast, lunch and supper formed significant

variables. It was suggested that any campaign against malnutrition must be

implemented within the framework of existing food patterns12.

A descriptive study conducted in Dharawad by the Population Research

Centre to determine individual, household, programme and community effects on

childhood malnutrition in rural India. The results showed that maternal

characteristics such as socioeconomic and behavioural factors were more

influential in determining childhood nutritional status than the prevalence of

programme factors13.

The above studies and statistics suggest that mothers are primary caregivers

of children and the causes of malnutrition are preventable through education. So

mothers should have adequate knowledge on nutritional status of their

children.Hence there is need to conduct a study and share information on

nutritional needs and factors affecting nutritional status of preschool children to the

mothers.

SCOPE OF THE STUDY

Children under 16 years of age constitute over 40% of India’s population and

information about their mental health need is a national imperative.1 Identification

and handling of behavioral problems of childhood is very essential because nations

most important and precious resource is its children who constitute its hope for

continued achievement and productivity. Today we are passing through a stage

where the mental health of youngsters is a matter of much concern for the

educationists, psychologists & sociologists. Now a day’s suicidal tendency is more

common in school children and adolescent groups. It is a burning issue today. So

early prevention & intervention is better then later remediation.

In the studies conducted over the last fifty years, prevalence rate of behavior

problems varied from 5% - 51%. In the Indian studies prevalence rate varied from

13 per thousand to 431 per thousand. Analysis at pediatric out patients department

reveled behavior problems in the range of 3.36% to 50%. Single parenting and

violence have been associated with increased behavioral in children. Hence parents

and teachers are interested in good beginning for children.5

Karande.S et al (2007) conducted a prospective observational study on

clinical and psycho educational profile of children with specific learning disability

and co-occurring attention deficit hyperactivity disorders in Mumbai India. 50

consecutively diagnosed children were included in the study. SpLD was diagnosed

and diagnosis of ADHD was made by DSM-IV-revised criteria. Detailed clinical

and academic history and physical and neurological examination findings were

noted. In that, 12 (24%) had delayed walking, 11 (22%) had delayed tiling, 5(10%)

had microcephally, 27 (54%) displayed soft neurological signs and 10 (20%) had

primary nocturnal enuresis. There were no differentiating features between the two

gender groups. Their academic problems were difficulties in writing (96%) in

attentiveness (96%) difficulties in mathematics (74%) hyperactivity (68%) and

difficulties in reading (60%0 all children had poor school performance, 15(30%)

had already experienced class retention and 20(40%) had developed aggressive or

withdrawn behavior children with SpLD and co-occurring ADHD need to be

identified at an early age to prevent poor school performance and behavioral

problems.6

Research into the prevalence of emotional and behavioral disorders in young

children is relatively new, and its development is challenged by the question as to

what really constitutes an emotional or behavioral problems. Still recent studies

estimate that the prevalence of behavioral and emotional problems in pre school

children has increased over the past two decades to more than 10%. This number is

considerable higher among Pre School & children who live in at risk environment

(Gimpel and Holland). Research has shown that the emergence of early onset

conduct problems in young children is related to a variety of health and behavior

problems such as peer rejection, drug abuse depression and school dropout in later

years. So a right start in the early years is an invaluable aid to continuous unfolding

of a child’s potentials.2

CONCLUSION

“A descriptive study to assess mothers’ knowledge on factors affecting

nutritional status of preschool children in selected rural areas of Mangalore

Dakshina Kannada with a view to develop a health education pamphlet”.

Assumptions

The investigator assumes that

1) the mothers from selected rural area will have some knowledge regarding

the factors affecting nutritional status of preschool children.

2) there are certain factors affecting nutritional status of preschool children.

3) health education pamphlet will increase the mothers’ knowledge on

factors affecting nutritional status, prevention and management of

malnutrition.

6.7 Delimitations

The study is delimited to:

1. the investigation of a rural area.

2. the study is delimited to the mothers of preschool children .

3. the mothers who would be able to respond to the investigators questions.

4. mothers available at the time of data collection.

REFERENCES:

1. World Health Organization, Make every mother and child count, WHO Report2005 Report 2005, Available from: www.who.int/whr/2005/en/.

2. Marlow D, Redding BA. Textbook of paediatric nursing. 6th ed. Philadelphia: W. B. Saunders Company; 2001.

3. Parul Christian, Rita Abbi,Sunder Gujral and Tara Gopaldas ,The role of maternal literacy and nutrition knowledge in determining childrens nutritionalstatus,Availablefrom:URL:http//www.unu.edu/unupress/food /8F104E06.htm

4. Parul Christian,rita Abbi,Sunder Gujral and Tara Gopaldas ,The role of maternal literacy and nutrition knowledge in determining childrens nutritionalstatus,Availablefrom:URL:http//www.unu.edu/unupress/food /8F104E06.htm

5. WHO, Nutrition for health and development ,Available from :URL:www.searo.who.int/LINKFILES/Nutrition for health and Development conclusiosandrecommendations.pdf

6. Globe Nutrition. Global and regional trends in the estimated prevalence of protein energy malnutrition. Available from: URL:http://www.who.com .

7. District Health Office. Report of ICDS project on monitoring nutritional status of under five children at Mangalore, 2007.

8. Child feeding and nutrition (2-5 years age). Available from: URL:http://www.who.int/child-adolescent health/NUTRITION/child.htm.

9. Core health indicators. The latest data from multiple WHO sources. Available from: URL:http://www.who.int/ whosis/database/core/ .

10. WHO. Survey: More Indians than Chinese go hungry. Available from: URL: http://timesofindia.indiatimes.com/Resurgent_India_goes_to_bed_hungry /articleshow/2457204.cms.

11. Saito K, Korzenik JR, Jekel JF, Bhattacharji S, A case control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India. Yale J Bio Med; 70(2):149-60.

12. Hasan J, Khan Z, Sinha SN. Socio-cultural factors influencing nutritional status of infants – a longitudinal study. Indian J Maternal Child Health 1991;2(3):84-6.

13. Lazarus T, Bahana K. Nutritional histories of severely and moderately malnourished and adequately nourished Indian preschool children. J Afr Med 1985 Sep 28; 68(7):479-82.

14. Rajaram S, Zottarelli LK, Sunil TS. Individual, household, programme and community effects on childhood malnutrition in rural India. Dharwad: Population Research Centre.

15. Devi YP Geervani P. Determinants of nutrition status of rural preschool children in Andhra Pradesh, India. Available from: URL:http://www.UNU.edu/UNU press/food/V191e/Cho.

16. Salah EO, Mahgoub, Neyepi N, Bandeke T. Factors affecting prevalence of malnutrition among children under three year of age in Botswana. Available from: URL:http://www.ajfand.net.

17. Gupta MC, Mehrota M, Arora S, Saran M. Relation of childhood nutrition malnutrition to parental education and mothers’ nutrition related KAP. Indian Journal of Paediatrics 1991 Mar-Apr; 58(2)269-74.

18. Bhat IA, Shah GN, Dhar GM, Mehnaz S. A study on the impact of maternal knowledge and practice on the nutritional status of infants. Indian Journal of Maternal Child Health 1992 Jan-Mar; 3(1):12-5.

19. Ergul T, Turgay U, Turgay C. Indicators of nutritional status in Turkish preschool children: results of Turkish demographic and health survey. Oxford Journals 1993; 42(2):78-84.

20. Usha P and Moly Kuruvilla.  “Supporting system and certain bahaviors problems of

preschool children in Malappuram District”. India. Project Report 2002.

21. Javelin C.M.S, Jon Roth M.D. Medical practice in Edmond, Oklahoma, dedicated to

helping families by evaluating children with developmental and behavioral issues.

22. Roy D’Silva. Ads by Google.http.www.buzzle.com

23. Ashenafi Y Kebede D, Desta M, Alem A. Prevalence of mental and behavioral disorders

in Ethiopian children.  Department of Community Health, Addis Ababa University,

Ethiopia. Arch Pediatr Med. 2004 Aug. 158(8); 766-72

24. Bear, G. G1995, Best practices in school discipline. UCLA centre for Mental health in

schools/Los Angeles. Email. smph@ucla.ed.

25. Stanhope, Lancaster. “Community health nursing”. 4th edition, Mosby Publications, 1996

P 537.

26. M. Rajamanickam Book. 1st edition, publishers GNOSIS, Jan. 2007

www.bagchee.com/books.

27. Palo Alto Medical foundation. http;/www.pamf.org

28. Syed EU et al. “Screening for emotional and behavioral problems against 5-11 year old

school children”. Socio Psychiatry Psychiatr epideniol 2007 May, 42(5):421-7 (2007)

29. Doctors speak out for Reform. http./familydoctor.org.

30. Shoba Srinath et al. “Epidemiological study of child and Adolescent psychiatric disorders

in urban and rural areas of Bangalore. India”/ 2005 July Indian Med Res. 122, PP 67-79.

31. Nirmala Gangaduri.  A study to assess the knowledge and attitude of School Teachers on

behavioral problems of children.  Unpublished dissertations. Submitted to Bangalore

University, NIMHANS.

32. Maj. J. Prakash< Brig S. Sudarsanan, Col P K Pardal, Col. S. Chaudhury (Retd.) et al.

“Study of behavior problems in a pediatric outpatient department”. India. MJAFI 2006

62:339-341.

33. Sivaharimani. Emotional and Behavioral problems of school children. 01-25-2008.

34. Gupta I et al. “Prevalence of behavioral problems in school going children”. Ludhiana,

India. Indian pediatric 2001 Apr. 68(4): 323

35. Kumpulaineen K. Rasanen E. Henttonen I. Piha Jet al. Comparative study on parent’s and

teacher’s reports of elementary school children’s behavioral and emotional problems.

Kupio University Hospital, Department of Child Psychiatry, Finland. 1999.

36. LloejeSO, Rutter’s behavior scale (B2) for children (Teacher’s scale), validation and

standardization for use on Nigerian children.  East AfrMed.June 2001, 78(6) 308-11.

37. SyedEU,HisseinSA, Haidry SE, Prevalence of emotional and behavioral problems among

primary school children in Karahi, Pakistan—multi informant survey. Indian Pediatric J.

Jun 2009; 76(6): 623-7.

38. Elhamid AA, Howe A, Reading R. Prevalence of emotional and behavioral problems

among 6-12 year old children in Egypt, Eur Child Adolesc Psychiatry. Dec; 2008-,17

39. SyedEU,HisseinSA, Haidry SE, Prevalence of emotional and behavioral problems

amongst 5-11-year-old school children in Karachi, Pakistan, Department of Psychiatry,

The Aga Khan University, Karachi, Published by Int J Soc Psychiatry. 2000 winter;

46(4): 266-80.

40. loeber R, Burke J D, Pardini D A. Develpoment and etiology of disruptive and delinquent

behavior. Department of Psychiatry, medical school, University of Pittsburgh, USA.

loeberr@upmc.edu

41. Beesdo K, Knappe S, Pine Ds. Anxiety and anxiety disorders in children and adolescents.

Clinical psychology and Psychotherspy,. 2009 Sept.: 32(3): 483-524.

42. Morawaka A, Sanders M. An evaluation of a behavioural parenting intervention for

parents of gifted children. School of Psychology, University of Queensland, Australia.

alina@psy.uq.edu.au

43. Turner W, Macdonald GM, Dennis G A. Cognitive Behavioral training interventions for

conduct disorders among children and adolescents. Cochrane database. Syst Rev. Jan

2010

44. Dretzke J, Davenport C, Frew E, Barlow J, Stewart-Brown S, Bayliss S et al. The clinical

effectiveness of different parenting programmes for children with conduct problems- a

systematic review of randomosed control trail. Annu Rev Clin Psychol. 2009: 5: 291-310.