Post on 02-Feb-2023
An Information Design Thesis Presented to
The Fine Arts Program of theAteneo de Manila University
In Partial Fulfillment of the Requirements for the Degree
Information Design
ByJustine Bugarin Ong
March 2012
01 Introduction
My interest in child life work began when I met LJ, one fine morning on January 29, 2006.
My mother took me to the Pediatric Ward of Armed Forces of the Philippines because every
year, on the third Sunday of January, they celebrate through a party with the children on
the feast of the Sto. Nino (Child Jesus). She asked me to bring some toys with me, toys that I
played with when I was a child, so that we could give them to the children in the hospital.
When we were in the hospital, she told me to give them to the children myself. So I went
into a room and I found a little girl, sitting up on the bed, playing with her own toys. I came
up to her and I noticed that in one of her eyes was a halo-like ring right in her pupil. No-
ticing that I was perplexed by what I saw, her father told me that she had retinoblastoma,
a kind of cancer in the retina which is the light receptor of our eyes. At that moment I knew
that I would not be able to forget the little girl who appeared to have light in her eyes.
If there was a way to make a playful and a holistically-nur-
turing environment for pediatric oncology patients who lie in
bed, day and night, I would be more than willing to devote my
time and skill. During the patients’ stay, the medical profes-
sionals would advise them of the best method for treatment,
but more importantly prepare them emotionally for the medical
procedures and sensations that they will undergo. Their fami-
lies would aid the children by making them understand their
illness, and provide them with the strength that they need.
Liblaro will answer to these needs. It is an educational therapeutic play method that promotes child life care which prioritizes emotional awareness in terms of understanding the nature of the illness, and also provides physical and emotional preparation for medical procedures.
Inspired by this persistent memory, I devised a way to make
hospital treatments for pediatric oncology patients less daunt-
ing and stressful. In reality, hospitals, more often than not,
add to the amount of stress that the patients are experiencing
because of strange and unfamiliar environmental conditions
such as uncanny hospital equipment and medical instruments
and stiff mattresses held by cold metal frames. Not to mention
the severe and silent strangers in white laboratory gowns and
uniform- doctors and nurses who are immediately responsible
for the willingness of the patient to respond to treatment.
Keywordspediatric oncology patients, therapeutic play technique, symbolic play, therapeutic metaphors, content analysis, Communication Accommodation Theory
therapeutic play technique
“Therapeutic play, (including play therapy), is a well estab-
lished discipline based upon a number of psychological theo-
ries. Research, both qualitative and quantitative shows that
it is highly effective in many cases. Recent research by Play
Therapy United Kingdom (PTUK) suggests that 71% of the
children referred to play therapy will show a positive change.
A safe, confidential and caring environment is created which
allows the child to play with as few limits as possible but as
many as necessary (for physical and emotional safety.) This
allows healing to occur on many levels following our natural
inner trend towards health. Play and creativity operate on
impulses from outside our awareness- the unconscious. No
medication is used.” (Play Therapy International database)
pediatric oncology patients
patients from five to twelve years of age with childhood cancers
Symbolic play
Symbolic play is “ the assimilative process, which enables
children to practice at symbolically representing objects and
events”(Pellegrini in Stone’s “Symbolic Play and Emergent Lit-
eracy”, p.1).
therapeutic metaphors
“Fernandez (1977) states that metaphoric statements represent
metaphoric images, which he considers plans of action.
Helping patients bring their metaphoric images back to life
stimulates them to further develop these plans of action and
eventually to implement them.” (Witzum et. al in “The Use of
Metaphors in Psychotherapy,” 1988, p.2)
Selected Published Articles on measurement tools to be used
Communication Accommodation Theory
Communication Accommodation Theory (Coupland et al. 1988)
identifies five key dimensions to the social semiotic exchange
between patient and clinician: attuning strategies, interpret-
ability, discourse management, interpersonal control, and
approximation. The final semiotic mediation occurs when the
researcher’s data on efficacy are gathered and coded in two
ways: content analysis of audio recorded patient/clinician
conversations and patients’ responses post-intervention to a
survey on their symptoms. (Long, Thomas Lawrence.
“Pain as Sign and Symptom: A Semiotic Analysis of Nursing
Clinical Practice and Research.” Presentation, Eleventh In-
ternational Gathering in Biosemiotics, New York, NY, June
21-26, 2011.)
Content analysis
Graneheim UH, Lundman B. Qualitative content analy-
sis in nursing research: concepts, procedures and mea-
sures to achieve trustworthiness. Nurse Educ Today. 2004
Feb;24(2):105-12.
This paper provides an overview of important concepts (man-
ifest and latent content, unit of analysis, meaning unit, con-
densation, abstraction, content area, code, category and
theme) related to qualitative content analysis; illustrates
the use of concepts related to the research procedure; and
proposes measures to achieve trustworthiness (credibility,
dependability and transferability) throughout the steps of
the research procedure. Interpretation in qualitative content
analysis is discussed in light of Watzlawick et al.’s theory of
communication.
Selected Published Articles on Chronic Illness and its Effect on the Patient and the Family
Dora Black, Family Intervention with Families Bereaved or
About to be Bereaved. (USA: Hemisphere Publishing Corpo-
ration, 1991) 140-142.
Chronic or life threatening illness in a child has effects in
the family, and on their relationships to each other and to
people outside the family (Black and Wood in “Children and
Death”, 1989) The incidence of behavior problems in leuke-
mic children is high, and this may be related to the lack of
openness within the family. Studies of morbidity in the sib-
lings of sick children show high rates (up to 75%) of psycho-
logical disturbance. The parents, too, present high levels of
psychological problems. Marriages are put under stress by
the demands of the sick child and by the treatment needs,
which often separate parents and increase work and financial
strains. The siblings of dead children also show high rates of
disturbance. Given this high morbidity, there seems to be a
role for the therapeutic intervention with at risk families. In
our department at the Royal Free Hospital, London, a team of
child psychiatrists, psychologists, social workers, family ther-
apists, psychotherapists and psychiatric nurses offers services
to families facing the life threatening illness of one of their
members. We are currently evaluating the relative efficacy of
individual and family therapy with children in end-stage renal
failure. In a pilot study we have found high levels of morbid-
ity in these children (Mcfayden, Balck & Trompeter, 1991) af-
fecting compliance with medical treatment (Altschuler, Black,
Trompeter and Fitzpatrick, 1991). Other issues that need to be
addressed are connected with changes in the child as a result
of treatment (e.g. intellectual deterioration) and child care
issues, particularly those of siblings. Illness changes families.
Finally, it is important to address issues of death and dying
in an open way within the family. Parents try to protect their
children from the realization that an illness is potentially fa-
tal, but various studies have shown that, at some stage, chil-
dren learn their prognosis, although they may protect their
parents from becoming aware of their knowledge. Bluebond-
Raimbault, Ginnet “The Seriously Ill Child…” USA: Hemi-
sphere Publishing Corporation, 1991
By fostering children’s epistemophilic drive, their quest for
what could be considered as specific, personal, subjective
truth and maintaining those exchanges with them, we will
keep them “alive” even though they are close to death.
Langner (1978) has written about “mutual pretense,” which
is maladaptive and certainly results in loneliness and isola-
tion for the child. It is important to work within the family’s
belief system while helping parents to reframe religious be-
liefs in a mentally healthy and developmentally compre-
hensible way. In a recent article (Black, 1989) that reviewed
the results of various family therapy studies with children
facing life-threatening illness, only one study ebaluated
family therapy and it was found to be effective (Bellomo,
1986).
Design PhilosophyThe only way to encourage response is to tap into intuitive design. This is precisely what Gestalt psychologists suggest- that
by minimizing the cognitive load of information in design
allows the human mind to unconsciously recognize pat-
terns. Therefore, this “preattentive processing” paves way
for the perceiver to focus on decision making and attaining
the objectives of the activity. Satoshi Itsuka, a furniture
designer, talks about the same principle of concept-driv-
en product design through “secondary communication.” It
only means that a subtle message is implied in the content
of the design by making it an integral part of the design
process- from conceptualization to prototyping.
The mean age for children in the Pediatric ward is apt for
this kind of pattern recognition and replication. Children
from ages five to twelve, identified by Freud’s stages in
child development to be in Latency, are much attuned
to sensory or creative play. By being drawn to creative
art, books and stories, music and pets, they develop
their physical and motor skills which is essential in their
growth. Fine-motion activities like board games with rules
and jigsaw puzzles increase eye-hand coordination. In
this age, they also discover differences in roles such as
being a mother, father, teacher and other traditional roles
through symbolic or pretend play. They appreciate gen-
der-appropriate roles in play and are interested in sym-
bolism in the use of ordinary objects in pretend play like
the idea of superheroes, talismans, imaginary compan-
ions, and dressing-up. Self-esteem is developing in this
stage also. Therefore, the design should emphasize their
ability to do things on their own.
Most especially, these children are patients who are exposed
to trauma and stress, brought about by the entirety of the
hospital experience. Their motor and physical development
is hampered primarily because they are afflicted with chron-
ic diseases that limit their freedom in movement due to the
different medical procedures that they undergo. Interaction
through social play is also limited because of mood fluctu-
ation and discomforts brought about by the side effects of
medicine. Family relations are affected in such a way that
the family’s living pattern is altered by structural changes or
financial matters. Child life care is specifically targeted in en-
suring that the child gets the full emotional support he or she
can get by involving the family members and medical pro-
fessionals in the process. Kythe Foundation, the brainchild
of two Ateneo de Manila Psychology graduates Maria Fatima
Garcia-Lorenzo and Icar Castro, advocates in addressing the
psychosocial needs of the child patients. In an organizational
research conducted by Lim Uy, it described the goals of the
Child Life Program, Kythe’s primary objective: “The possible
interventions provided by CLP includes psychosocial need
assessment of the patient and the family, education regard-
ing the illness, preparation for and assistance during medical
procedures, therapeutic play, and hospice care. In the end,
everyone benefits from this program—the patient, the family
and the health care providers. Kythe Foundation attempts to
institutionalize CLP in each of their hospital affiliates in order
to seek an improved quality of life for their pediatric patients
by uplifting their spirits and providing a spark of hope to their
family.”
From this principle, the concept of reinforcing the capa-
bility of the children to succeed despite chronic illness is
of primary importance. Letting them be their own char-
acters in their story proves to be the optimal solution to
help them build on their self-esteem. By using therapeutic
metaphors such as being the superhero, or the victim be-
ing saved from death which all arise from symbolic play,
we may be able to engage the patients in a playful and a
holistically nurturing environment. Using familiar objects
that belong to them will tap into the possibility of relating
with age-old archetypes, and a probable tool for assessing
the patient’s self-concept. From the sensory experience of
interacting with the objects around them, poetic imagery
will be formed. All types of image, may it be visual, audi-
tory, tactual, gustatory, olfactory and motor will allow the
play technique to function. Thus, these images will be the
source of inspiration for symbolic play, and the internal
resolution that will be formed upon realizing the moral of
the story. This is what Liblaro aims to provide to these chil-
dren, their families and most especially to the health care
industry.
Liblaro is a therapeutic play technique that hopes to encourage self-expression, communication and personalized learning among pediatric oncology patients, from ages five to twelve who are in hospital care. It involves a storybook mat-tress that engages the sensory aspects of play. The intuitive quality of interact-ing through the objects that the child patients normally get in contact with, and also through a familiar play technique which fuses storytelling and symbolic play would allow them to create plans of action towards their ideal selves. Synesthetic responses are elicited from sensory play as the patients are asked to “tag” their emotions with colors. After which, they identify a particular thing, animal, or place that comes to mind upon seeing the color.Apart from visual stimulation from the visual design of the mattress, other sensory responses from the sense of touch and hearing are involved.
Designing an exclusive experience of play for each patient will encourage them to acknowledge and understand their emotions and give it a visual representation through learning and play modules that will involve every-one, including the patient, the family members and health care providers. They will also have therapeutic play groups wherein first they will be as-sessed through qualitative research techniques such as content analysis and semiotic analysis.
As the storybook mattress will engage the senses, several methods of production will be used. Heat sensitive ink will be utilized as to engage the sense of touch and to establish a child-directed activity as the patient gains a first-hand experience of the material.
1.4 Toward this end, I plan on doing the following:
1.4.1 Develop Liblaro as a therapeutic play technique that involves
symbolic play by pediatric oncology patients and their family members
1.4.2 Use therapeutic metaphors in play to instil positive self-esteem
1.4.3 Appropriate the design solution to effect mood improvement,
enhance quality of verbal and emotional disclosure, increase treat-
ment compliance and improve family relations
1.4.4 Kaizen which means “improvement” in Japanese, will be the to-
tal objective for this design research. Research as a conversation will
answer the psychosocial needs of the patient, and as well as his or her
family’s needs. This is also in line with the effort to institutionalize
therapeutic play as part of treatment in Philippine health care.
In line with Kythe Foundation’s thrust to institutionalize therapeutic play in hospitals, this research will involve the participation of their partner hospitals such as the Armed Forces of the Philippines Medical Center (AFPMC) through the Dra. Canonizado of the Pediatric ward. Ateneo- Kythe will integrate this therapeutic play technique in their hospital visits. Consultations with Mr. Ar-senio S. Alianan Jr., Assistant Professor at the Ateneo de Manila Psychology Department will provide clinical advice. The Philippine Association for Child and Play Therapy will investigate on the development of this new technique by doing an in-depth research.
This design research will focus on developing the appropriate therapeutic play technique for pediatric oncol-
ogy patients from ages five to twelve who are military dependents in the AFPMC. It is not an attempt to create
a play therapy technique because of issues in professional standpoint. However, it may be possible foundation
for future research by accredited play therapy professionals.
The results of this research are evidence-based, thus there is a potential source of interviewer and selection
bias. Its impact on the later stages of the research will not affect the qualitative measurement from observa-
tion because of its nature as a design research. This qualitative measurement involves analyzing the appro-
priated design solution to effect mood improvement, enhance quality and quantity of verbal and emotional
disclosure, increase treatment compliance and improve family relations.
Liblaro is for the pediatric oncology patients of the affiliates of the Kythe Foundation, particularly the patients
in the Pediatric ward of the AFPMC. It will address their psychosocial needs for therapy while in medical treat-
ment. Also, the families of the patients are closely affected due to their intervention in the therapeutic play
technique. Most of these patients and their families may be undergoing trauma and depression from altered
lifestyles due to prolonged hospitalization, shift in family roles due to an ill family member and affected fam-
ily relations because of the amount of attention the ill family member is being given compared to the other
siblings.
Project Backround02
Carey in “Child and Adolescent Depression : Cognitive- Behavioral Strate-
gies and Interventions” said that symptoms of depressions such as sadness
or dysphoric mood emerge from clinical settings among children and ado-
lescents, as observed by clinicians and researchers. The challenge begins
with the fact that the child patients have not yet undergone complete psy-
chological, educational, or even neurological development. This is what
White talks about in “CLAYtherapy: The Clinical Application of Clay with
Children.” He says that “these children bring near impossible-to-solve life
issues combined with severe, sometimes multiple, diagnoses. They often
are resistant, usually without a grasp of the clinical procedure and fearful
of this mysterious and unprecedented process they are forced to endure.
They come to an unknown adult, not of their choosing, and are asked to
talk and play with him or her behind closed doors.”
This design research hopes to answer their psycho-
social needs by effective means of mood improve-
ment, enhance quality and quantity of verbal and
emotional disclosure, increase treatment compliance
and improve family relations. Through Liblaro, the
present condition of therapeutic play in hospitals
may also be addressed.
Since every research is a conversation, the approval and participation of hospi-tals is of utmost importance. This research also aims to look into the current situation of our health care providers and how it is closely linked to the quality of rehabili-tative treatment it is giving. For this pur-pose, the project is for the AFPMC since it is the locus of the study.
In the Department of Health website, the rate of incidence was predicted in a study conducted in 1998. It said that among children with cancer, 3.7% (1, 536 cases) are male and 2.6% (1,171 cases) are female in the total of 2, 707 cases. Leukemia is the most prevalent kind of childhood cancer, followed by cancer in these sites- brain and ner-vous system, retina, lymph nodes, kidney, bone and soft tissues, gonadal and germ cell sites.Early prevention and detection might have reduced
the incidences of childhood cancer, especially be-
cause they are more likely to recover from these ill-
nesses. However, the lack of effective information
dissemination, financial implications of medical
check-ups and the abandonment of clinical treat-
ment affects the survival rate of Filipinos with child-
hood cancer.
As what the World Child Cancer organization mentions
in their website, the Philippines has no national model
for care and treatment of children with cancer. It is im-
portant therefore, to re-evaluate our policies with regard
to health care provision. More children are diagnosed
today from that of the statistics shown in the 1998 study,
and an even more alarming rate of children who are di-
agnosed yet untreated makes the need for research more
of a pressing issue that plagues our society today.
Even the locus of medical research is a reflection of the current state of health care. Most sources for medical research
come from Western countries, especially from the United States of America. Asian
countries such as Indonesia, India and China have also been taking lead, but
only a few published researches are from the Philippines.
“Twinning programs” have been created in order
to help developing countries improve health care
conditions. AMOR is a cooperative effort in Central
America which essentially is about creating linkag-
es between health care providers in the developed
world and the local pediatric oncology unit.
Play therapy in the Philippines is practiced only by licensed professionals. Local government institutions such as the De-partment of Social Welfare and Development have initiated some development in their practice as seen in the use of play therapy on children evacuees. We are slowly inching in to-wards a sustainable change in our health care practice. This is the kind of positive change that we endeavor through this project.
Through Kythe Foundation, the AFPMC adapted the child life program where-
in the psychosocial needs of the children and their families are met. However,
the patients who participate are those who are able to move to the Kiddie
Corner in the event that they would want to play with the Kythe volunteers.
This proves to be a limitation for the program itself because it excludes those
patients who are currently advised to stay in bed. Also, the health care pro-
viders, in this case, the doctors and nurses that interact with the patient and
their families, have limited participation in practicing the child life program.
Although contemporary play therapy using creative art as a technique would argue that the therapy room is a symbolic space for both the patient and the play therapist , the practical space of their bed in their clinical ward is being elevated to the most intimate symbolic space there is. This is where they could still get in touch with their families while in the process of symbolic play, and also where they nourish themselves with food, share stories with other pa-tients, undergo treatment, get in touch with their families- where they feel loved and cared for. Associating this place to a positive energy will not only help them make “representations of experience” but more importantly create a feeling of exclusivity, that this is a place where they can feel comfortable and imagine freely. The hospital bed becomes the closest creative arena to them.
According to the Association for Play Therapy in “Culturally Competent Play Therapy with the Mexican American Child and Family,” (Robles, 2006) a play therapist must make culturally-appropriate interventions. What makes Liblaro intrinsically a localized intervention is the fact that it involves the family of the patient as it reflects the culture of close family relations as it is in Filipino culture.
Methodology04Liblaro is a therapeutic play technique that hopes to encourage self-expression, communication and personalized
learning among pediatric oncology patients, from ages five to twelve who are in hospital care. It involves a story-
book mattress that engages the sensory aspects of play. The intuitive quality of interacting through the objects that
the child patients normally get in contact with, and also through a familiar play technique which fuses storytelling
and symbolic play would allow them to create plans of action towards their ideal selves. Synesthetic responses are
elicited from sensory play in using heat sensitive ink technology in the production of the mattress. Apart from visual
stimulation from the visual design of the mattress, other sensory responses from the sense of touch, taste, smell and
hearing are involved.
Designing an exclusive experience of play for each patient will encourage them to acknowledge and understand
their emotions and give it a visual representation through learn¬ing and play modules that will involve everyone,
including the patient, the family members and health care providers. They will also have therapeutic play groups
wherein first they will be assessed through observation measurements such as the Trauma play scale, and through
structure assessments such as the Cooper-Smith Self- Esteem Inventory, Child Behavior checklist and the Kinship
Center Attachment questionnaire- all approved research measurements, and then finally grouped together.
As the storybook mattress will engage the senses, several methods of production will be used. Heat sensitive ink
will be employed to as to engage the sense of touch, just as it was used in Jordan Crane’s Book entitled “Keep Our
Secrets.” Using edible ink on rice paper is also be a medium for production. A mixed media work will be created.
Scope and limitations06This design research will focus on developing the appropriate therapeutic play technique for pediatric oncology
patients from ages five to twelve who are military dependents in the AFPMC. It is not an attempt to create a play
therapy technique because of issues in professional standpoint. However, it may be possible foundation for future
research by accredited play therapy professionals.
The results of this research are evidence-based, thus there is a potential source of interviewer and selection bias.
Its impact on the later stages of the research will not affect the qualitative measurement from observation because
of its nature as a design research. This qualitative measurement involves analyzing the appropriated design solu-
tion to effect mood improvement, enhance quality and quantity of verbal and emotional disclosure, increase treat-
ment compliance and improve family relations.
Design
06Liblaro
Patagonia 0123456789abcdefghijklmnopqrstuvwxyz!@#$%^&*()_+{}|:”<>?[]\;’,./
Liblaro pattern
for merchandise such as t-shirt and stationery
Fontface
Vertical Logo
Horizontal Logo
Proof of Concept
Hindi pa sumisikat ang arawnang pumalaot kamipara mangisda sa dagat. Matapos kong humakbang papasok sa bangka at umupo sa gitna nito, tinulak ni tatay ang bangka palusong sa mas malalim na tubig. Maya-maya, sumakay na rin siya at nagsimulang magsagwan.
At nang nakalayo na kami, tinanong ko si tatay, “ Ano po kaya ang mahuhuli natin ngayon?”
“Alam mo naman ang sabi nila, ang dagat ay
parang isip ng tao, kalaunan ay lilitaw rin
ang mga bagay na iyong naaaalala mo
mula sa nakaraan,” sabi niya.
13
2
4
Anong kulay ang
nagpapaalala
sa iyo ng
nararamdaman
mo ngayon?Anong naaalala
mo mga bagay,
hayop at lugar sa
kulay na ito?Magpatulong
kay ate at kuya
na gumawa ng
“stencil”
Pinturahan ang kumot. Kapag
tuyo na, maari mong hawakan
at pagmasdan habang
nagbabago ang kulay nito!
Subukan mo! Liblaro User Manual
This manual will aid the child life specialist to implement the thera-peutic play method approved by Kythe and AFPMC
Exhibit
07
Results08
Based from the comments from those who participated in the exhibit, valid points for improvement arose. Around 80% of the total comments pointed out the importance of the manual as it will instruct not only the child, but most especially the child life specialist that will implement the therapeutic technique- may it be the medical professionals or the family members of the patient.. Since this program is still under the evaluation of the AFPMC Ethics board, it would be best to clearly map out every step of the thera-peutic play technique.This fact was also pointed out by the panel during the final thesis defense
Many people were curious about the heat-sensitive ink and asked if it had traces of toxicity which may affect the health of the patient. This fact is under consideration as the pigments used will be formally tested for toxicity or al-lergic reactions. Alternatives such as organic dyes may be used in lieu of the heat-sensitive pigment.
Future Applications09Basing from the comments, there is great potential in this project as it targets a problem-specific design solution. It can be applied to situations which cater to children with special needs and differ-ently-abled children. Liblaro can also be used in preschool set-tings. People from all ages could also find use in this project.
The program is applicable to any circumstance, as long as the pro-gram will be carefully reevaluated by psychiatrists and accredited play therapists.