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 persons 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 childs 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 childs 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 childs 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
Gods 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

problems and training in Self-help area13.

behavioral

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
knowledge

about

care of

having

deficient

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 childrens 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.

Bradshaws 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 childs 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 childs 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 mothers 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 childs 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 childs 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 childs 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 childs 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 pairedt 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 andt
value 29.27,14.
The study conducted on parents 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, childs 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 Childrens
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 childs play is recognized as a useful tool

for nurses in the diagnostic process of making judgments about a
hospitalized childs 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 differenceo 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 mothers 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 mothers knowledge on antenatal
care.
- Check list to assess the mothers 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 worlds
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 Indias 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 days 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 childs 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 healthcare-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 DSilva. 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 parents and
teachers reports of elementary school childrens behavioral and emotional problems.
Kupio University Hospital, Department of Child Psychiatry, Finland. 1999.

36.

LloejeSO, Rutters behavior scale (B2) for children (Teachers 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, Pakistanmulti 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.