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.

Timeline05

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.