Therapeutic Touch With HIV-Infected
Children: A Pilot Stud'Y
Mary Ireland, RN, PhD
In this pilot study, 20 HIV-infected children, 6 to
12 years of age, were randomly assigned into thera-
peutic touch (TT) and mimic TT groups. The effective-
ness of TT in reducing anxiety was evaluated. The
self-report measure, the A-State Anxiety subscale of
the Spielberger State-Trait Anxiety Inventory For
Children, was administered before and immediately
after interventions. As predicted, the TT intervention
resulted in lower overall mean anxiety scores,
whereas the mimic TT did not. These findings provide
preliminary support for the use of TT in reducing the
state anxiety of children with HIV infection.
Key words: Therapeutic touch, children, anxiety.
D e s p i t e the significant reduction in mother-to-infant
transmission of HIV and the improved health status of
infants receiving zidovudine (protocol 076)(Connor
et al., 1994), a cure for HIV remains elusive, and HIV
infection remains a threat to children over the next
decade (Gallagher & Klima, 1996). At the other end of
the perinatally acquired HIV infection continuum are
the infected children who are living longer. Natural
history data on perinatal HIV infection indicates that
the median survival age has increased from approxi-
mately 6 to 9 years (Grubman et al., 1995). Moreover,
there is an emerging population of older children with
later onset of clinical symptoms and prolonged
survival.
As HIV-infected children live longer, the stress that
they accumulate may put some at risk for severe emo-
tional distress (Lewis, Haiken, & Hoyt, 1994; Pol-
lack & Thompson, 1995). Because HIV infection is
accompanied by a pervasive stigma that elicits guilt,
shame, anger, and secrecy, it amplifies the impact of
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 9, No. 4, July/August 1998, 68-77
Copyright 9 1998 Association of Nurses in AIDS Care
psychosocial stressors. Those children who have had
their diagnosis disclosed to them experience the stress
of carrying the secret of HIV infection and may feel
contaminated. When there has been no disclosure, the
infected child often suspects something is wrong
because of the cues picked up from family members
and the frequency of physician visits and treatments
and drugs received. The heightened and prolonged
tension experienced under either condition can evolve
into a spiral of unrelieved stress that may be mani-
fested in a host of both physical and emotional
sequelae. Additional stressors that are unique to pedi-
atric HIV disease, social isolation, multigenerational
impact, interactions with previous family problems
such as drug addiction, and multiple losses (Lewis
et al., 1994) further intensify the child's trauma
accommodation.
Anxiety evokes a stress response and activates the
sympathetic nervous system, which, if sustained,
heightens physiologic and emotional reactivity and
immunosuppression, and increases infection risk
(Caudell, 1996). For these reasons, stress-reduction
techniques such as muscle relaxation, imagery, bio-
feedback, and hypnosis have been increasingly
employed to help alleviate the anxiety that accompa-
nies a range of pediatric conditions. An additional and
potentially effective techniqfie is the nurse-developed
complementary modality called therapeutic touch
(TI'). Research and practice literature suggest that
through TI', individuals can experience a relaxation
response: that is, a deactivation of two classic stress
response pathways, the hypothalamic-pituitary
Mary Ireland, RN, PhD, is an assistant professor at Rutgers
University, College of Nursing.

adrenal axis (HPA) and the sympatho-adrenal-
medullary (SAM)axis (Mulloney & Wells-Federman,
1996). Eliciting the relaxation response, reducing
anxiety, and interrupting the stress-symptom cycle
enhance the body's natural healing process, facilitate
recovery from illness, and prevent further complica-
tions. Tr, therefore, seems well suited for the treat-
ment of HIV disease. Indeed, recent findings offer
some support that TI" is not only a useful stress-
reduction intervention but may influence immunosup-
pression. For example, Garrard (1995) found an
increase in both coping skills and lymphocyte subset
pattern among HIV-infected males who had been
treated with T'I'. Although 22 healthy yet stressed
medical and nursing students facing professional
board exams showed no significant difference in state
anxiety scores following three "lq" treatments com-
pared to a no-treatment group, the "17"group changed
in the expected direction and had significantly less
decrement in IgA and IgM levels than did controls who
had no treatments (Olson et al., 1997). Despite such
promising findings with adults, there has been little
empirical investigation about the effectiveness of "IT
in children, and its potential to comfort and calm the
HIV-infected child has yet to be explored.
Background
Dolores Krieger (1979), introduced TI" to the nurs-
ing community in 1971. Her research questions cen-
tered on the idea that healing is a natural human poten-
tial that can be taught. She postulates hypothetically
that two factors are primary in the practice of TI': the
focused intention to heal and a transfer of energy from
environment, through the toucher, to and through the
subject. To date, this energy field has not been identi-
fied and the energy hypotheses not tested directly.
TT, then, is an intentionally directed process of
energy modulation during which the practitioner uses
the hands as a focus to facilitate healing (Mulloney et
al., 1996). It is an intervention that is passive in nature;
it does not require that the client consciously partici-
pate. The technique involves simultaneously centering
awareness, directing compassionate intention, and
modulating the flow of human energy through the use
of the hands. It may include physical contact, but it is
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 69
not a requirement for assessment and treatment. Nor is
its effectiveness contingent on the patient's belief in
the intervention.
TT Research
Of direct relevance to this study are the landmark
investigations of Heidt (1981) and Quinn (1982) who
examined the effect of "IT on anxiety. Although these
two investigators used different procedures for admin-
istering TT and different control protocols, both found
a significant decrease in state anxiety scores on the
State-Trait Anxiety Inventory (STAI) (Spielberger,
Gorsuch, & Lushene, 1970) in adult hospitalized car-
diovascular patients. After administering the STAI,
Heidt assigned participants to one of three groups on
the basis of matching scores. Group A received TI',
Group B casual touch, and Group C no touch. Quinn
randomly assigned subjects to two groups after partici-
pants completed the STAI. One group was treated with
TI' and the other with mimic "IT. Both investigators
used rigorous research designs and estimated adequate
sample sizes (N = 90 and N = 60, respectively) using
power analysis.
More recently, investigators have explored the
effectiveness of "17"in reducing state anxiety in diverse
populations, including the highly stressed Hurricane
Hugo survivors (Olson, Sneed, Bonadonna, Ratliff, &
Dias, 1992); a healthy sample of adults experiencing
an episodic stressful event, that is, students taking
examinations (Olson & Sneed, 1994); and adult
(Gagne & Toye, 1994) and adolescent psychiatric in-
patients (Hughes, Meize-Grochowski, & Harris,
1996). Data gathered in these studies are consistent
with that of previous studies, documenting that per-
ceived anxiety seems to decrease following "IT.
Of the few extant studies that examined "1"1"as an
intervention with children, none have focused exclu-
sively on the school-age child. Kramer (1990) exam-
ined the effects of TT on the stress response of 30 hos-
pitalized children 2 weeks to 2 years of age. After she
assigned children to one of two groups, "17" or casual
touch, baseline pulse, peripheral skin temperature, and
galvanic skin response were measured "at the time the
child was noted to be in stress" (p. 484). Significant
differences in the stress response in the TT group was
70 JANAC Vol.9, No. 4, July/August1998
found at 3 minutes and 6 minutes. Had Kramer
reported random group assignment, the number of
children per group, and what constituted stress behav-
ior, her findings would have been strengthened.
In a descriptive study of the healthy child's experi-
ence of receiving TF, France (1991) suggested that
children respond to "Iq" in ways similar to the adult.
Before and after four to six T1~treatments, she asked
11 participating children, (ages 3-9 years) to draw a
picture of how they felt and to talk about the drawing.
Statements of how they felt after q'q"differed from pre-
treatment descriptions. Several children said that TF
tickled, or was nice. One child stated, "I felt like air. It
was like static. I felt like static" (p. 80).
Purpose and Hypothesis
The bulk of ~ studies have been directed toward
Euro-American adults, with no examination of this
intervention with African American and Latino chil-
dren, the disproportionatley affected and largest group
of children who have HIV infection. In addition,
although standard treatments such as neuroleptics and
group therapy are reported to help these children cope
with their distress and relieve anxiety (Pollack &
Thompson, 1995), little systematically collected data
exists about psychotherapeutic intervention outcomes
in this population. The current study responded to
these research gaps. The immediate aim of this study
was to test the hypothesis that there would be a greater
decrease in posttest state anxiety scores immediately
following treatment in children treated with q'l" than in
children treated with mimic T'I'. Long-term goals are
to develop methods by which stress-reduction tech-
niques can be compared and tested for efficacy in
immunosuppressed children.
Interventions designed to reduce the stress response
may affect the physiologic and emotional reactivity of
children with HIV disease. By quantifying the stress-
related response called anxiety, the investigator aimed
to demonstrate that T'I" is an untapped resource that
may help ameliorate or modify the experience of living
with a chronic, yet life-threatening illness. If effective,
TT could ultimately help these children in their search
for normalcy and improve their quality of life.
Methods
Participants, Setting, Recruitment,
and Sampling Procedure
This was a convenience sample of 20 HIV-infected
children 6 to 12 years of age--the age range in which
A-state anxiety of the State-Trait Anxiety Inventory
for Children (STAIC) (Spielberger, 1973) is evalu-
able--living in a northeastern city that is an epicenter
of pediatric HIV disease. Recruitment was conducted
at two pediatric ambulatory care centers specializing
in HIV disease following institutional review board
approval. During clinic sessions, site intermediary
nurses at each center informed parents/guardians that
the author and two research assistants (RAs) were con-
ducting a study about the use of a nursing intervention
called T]" with HIV-infected children. If the par-
ent/guardian and child agreed to talk with the RAs, the
RAs showed them sample pictures from the screening
tool; the Peabody Picture Vocabulary Test-Revised
(PPVT-R) (Dunn & Dunn, 1981); sample STAIC;
A-State Anxiety scale questions; and consent, assent,
and demographic data forms. The consent form
explained that a child would be randomized to either
T1~ or a sham treatment called mimic T'l', and briefly
described the two treatments. Randomization was
described as the flip of a coin; heads up, a child is
placed in one treatment; heads down, a child is placed
in the other treatment. The RAs advised the par-
ent/guardian that they and their child would be told to
which treatment the child had been randomized fol-
lowing treatment. When signed consent was obtained,
randomization was initiated. Only children who met
the criteria for selection--that is, age 6 to 12 years,
English language dominant, no current psychotherapy
nor psychotropic or anxiolytic medication, and an
age-appropriate score on the PPVT-R--were included
in the study.
Training and Orientation of the RAs
Prior to data collection, the researcher introduced
the RAs to staff in each center, reviewed the issues of
disclosure and stigma, reinforced the importance of
preserving anonymity and confidentiality, trained

them in the administration and scoring of the PPVT-R
and STAIC, and instructed the mimic T r RA in that
technique. The hand and body movements of the
mimic qT RA were observed by the TT nurse expert
until they were deemed to adequately resemble those
used during TI'.
A script was developed with the RAs to standardize
and keep verbal interaction between the RAs and each
child to a minimum at the point of treatment. To estab-
lish the fidelity of the interventions, the researcher lis-
tened to each RA read the script and then, observed the
q~F clinician administer T r to the mimic RA and the
mimic RA administer the sham treatment to the q'T cli-
nician. This was done so that the investigator could
ensure that, to the naked eye, there would be no observ-
able difference in treatment application. The validity
of mimic TI' as a single-blind placebo control for TT
was previously established by Quinn (1982).
Data Collection Procedures
The two RAs visited the clinics once weekly, Janu-
ary 1997 through September 1997. Once informed
consent was obtained, each child received the treat-
ment to which he or she had been randomized, follow-
ing physician examination and/or treatment. The des-
ignated RA (either TF or mimic TF) took the child to a
quiet room and established rapport by introducing her-
self again and reading an assent form with the child. If
a child asked that a parent be present, this was permit-
ted. The RA, however, explained that neither the child
nor parent could talk during the treatment session.
After signed assent was obtained, the PPVT-R was
administered. If a child scored in the age-appropriate
range on the PPVT-R, the RA asked the child to state
how he or she felt and recorded the response, asked the
child to read the instructions for the A-State Anxiety
scale along with her, and asked the child to fill in the
questionnaire. Questions were answered, and the child
was allowed to complete the questionnaire at his or her
own pace. These tasks accomplished, the RA read the
standardized script and administered the treatment.
When the treatment was completed, the anxiety scale
was readministered and the child was asked to say how
he or she felt, and these responses were recorded. Most
children completed the scale pre- and posttest in
approximately 5 minutes.
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 71
At the end of the session, the parent/guardian and
child were informed as to which arm of the study the
child had been assigned. Children who failed to meet
the age-appropriate PPVT-R score were thanked for
their participation and returned to the parent/guardian,
without either being aware that the child had not met
the criteria for participation.
TT and Mimic TT Protocol
Quinn and Strelkauskas (1993) suggested that there
might be a relationship between the frequent practice
of Tl" and its effectiveness. In the current study, a nurse
who has practiced TT for more than 9 years, adminis-
ters it at least once a week in her practice, and has used
it with HIV-infected children administered "IT in the
manner in which it has been taught by Krieger (1979),
and as specified in Quinn and Strelkauskas (1993).
Specifically, the nurse systematically (a) centered her-
self by shifting awareness from an external to an inter-
nal focus, becoming relaxed and calm; (b) made the
intention mentally to therapeutically assist the child;
(c) moved her hands over the body of the child from
head to foot, attuning to the condition of the child by
becoming aware of changes in sensory cues in her
hands; (d) redirected areas of accumulated tension in
the child's energy field by movement of her hands;
(e) focused attention on the specific direction of ener-
gies to the child, using her hands as focal points; and
(f) directed energy by placing the hands 4 to 6 inches
from the child's body, one just below the waist and one
behind the back. Total treatment time lasted from 5 to
7 clocked minutes.
Mimic TI" is an intervention designed by Quinn
(1982) as a single-blind q'F placebo to control for the
fact that a treatment is being offered and, thus, the sub-
ject may expect relief. In this study, a TF-na'l've, fourth
year baccalaureate nursing student provided mimic
q'T. Quinn (1989) suggested that persons not experi-
enced with "IF are the best candidates to administer
mimic q'I'.
Systematically following this sequence within a
clocked 5-minute time frame, the student RA (a) made
the intention to imitate the movement ofTF; (b) focused
her attention on mentally subtracting from 100 by 7s;
(c) moved her hands over the body of the child from
head to foot while continuing to subtract from 100 by
72 JANAC Vol.9, No. 4, July/August1998
7s; (d) retumed to the child's head and repeated step c;
(e) placed her hands 4 to 6 inches from the child's
body, one in the area in the solar plexus and the other
behind the child's back, and counted backwards from
240; and (f) removed her hands when she had counted
down to 0 (Quinn, 1984, 1989).
Each treatment was given while a child sat sideways
on a chair, so that the back of the chair did not interfere
with access to the front and back of the torso and with
his or her feet flat on the floor. They were instructed
not to talk during the sessions unless discomfort was
experienced. The experimental and control condition
were administered by separate RAs who administered
their intervention to no more than 2 children during a
clinic session.
Instruments
The PPVT-R, a widely used instrument in evaluat-
ing receptive vocabulary in children, was used to
determine a child's ability to understand instructions
and follow directions. The score reported as a measure
of receptive vocabulary is a standard score equivalent,
or PPVT-R IQ. An examiner presents a series of plates
with four drawings per plate, says a word, and asks a
child to point to the picture of the word that he or she
has just said, and repeats this process until a child
reaches his or her critical range (those items that pro-
vide maximum discrimination among persons of simi-
lar ability). Administration takes approximately 10 to
15 minutes.
.,Split-half reliabilities for the L form that was used
in this study range from .67 to .88, test-retest coeffi-
cients for raw scores from .73 to .91, and standard
scores from .71 to .89 (McCallum, 1985).
The PPVT-R has been established as a valid tool for
African American and Latino preschool and school-
age children with AIDS (Ireland, 1994; Levenson,
Kairam, Bartnett, & Mellins, 1991) and for healthy
African American and Latino preschoolers (Ireland,
1994).
The STAIC (Spielberger, 1973), which was used to
measure state-anxiety pre- and postintervention in
each group, is a paper-and-pencil, self-report inven-
tory that is a downward extension of the adult STAI
(Spielberger et al., 1970). The A-State scale is com-
posed of 20 "I feel" sentence stems, designed to assess
the child's feelings at a particular moment. Each
response receives a weighted score from 1 to 3, with 3
representing the highest level of anxiety. Administra-
tion takes 8 to 12 minutes.
Spielberger (1973) reported Cronbach alpha coeffi-
cients of .78 for males and .81 for females for the
A-State scale. Papay and Hedl (1978) reported high
A-state internal consistency estimates for Black,
inner-city fourth-grade males (.82) and females (.80),
and moderately high estimates for the third-grade
males (.76) and females (.73).
The validity of the A-State scale has been estab-
lished in children with anxiety disorders, ages 5 to 17
(Strauss, Last, Hersen, & Kazdin, 1988); urban and
suburban, low to middle socioeconomic status, bilin-
gual (Spanish and English), and monolingual children
6 to 8 years of age (Murphy, 1990).
Data Analysis
Analysis of covariance (ANCOVA) was conducted
to test the hypothesis that there would be a greater
decrease in state anxiety scores immediately following
treatment in children treated with "IT than in children
treated with mimic TI'. Correlated t tests were con-
ducted to gain further perspective on these relation-
ships. Each child's open-ended responses before and
after treatment were reviewed to obtain a qualitative
perspective on the effect of T r versus mimic Tr.
Results
Of the 39 children recruited, 19 could not partici-
pate for the following reasons: (a) 5 were in foster care,
and the agency did not permit the guardian to sign con-
sent; (b) 3 were taking psychotropic medication; (c) 2
failed to score in the age-appropriate range of the
PPVT-R; (d) 2 did not wish to participate; (e) 4 could
not stay to participate; and (f) 3 parents would not con-
sent for the child to participate. As seen in Table 1, the
majority of the 20 participating children were female
(65%), African American (50%), and asymptomatic
(70%).
As noted in Table 2, most of the caretakers who
completed the demographic data form were mothers
(65%). Of these, 10 were biological, 2 foster, and 1
adoptive. Only 2 caretakers were biological fathers
 Ireland / Therapeutic Touch With HIV-Infected Children 73

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

of the mean difference in the experimental group, 2.5,

Table 4. Analysis of Verbal Responses Before and After
Treatment
however, was considerably lower than that reported by
either Heidt (1981) or Quinn (1984), who found mean
Group Before Frequency After Frequency decreases in state anxiety in their adult samples of 6.9
Experimental (TI') and 6.7, respectively. This could be explained by the
calm 2 calm 1 fact that pre treatment, their subjects were more anx-
happy 4 happy 2
fine 3 fine 1 ious with mean scores ranging from 36 to 38, whereas,
nervous 1 laughing 1 the current sample of children did not have mean
okay 1 good 4 scores greater than 32.
no comment 1 Examination of verbal responses to the question of
Control (mimic T'F)
good 1 good 1 how they felt prior to interventions suggests that this
great 1 great 1 was not an especially anxious sample of children.
happy 2 uncertain 1 These findings are consistent with those of Bose,
relaxed 1 dizzy 1 Moss, Brouwers, Pizzo, and Lotion (1994) in their
fine 3 fine 3 study of school-age children with HIV infection.
okay 1 okay 2
mad 1 weird 1 Although they studied primarily transfusion-infected
children living in middle-class families, those children
saw themselves as less anxious than respective stan-
dardization samples. If the stress that HIV-infected
Discussion children experience is as severe as assumed, then the
children in the current sample should have obtained
Recruitment and enrollment of 20 participants took scores reflecting more anxiety than they did. Some
6 months, reflecting the labor-intensive efforts required explanation is needed to resolve this apparent
in recruiting vulnerable populations with multiple incongruence.
demands on their precious time. Despite the aid of site As in the case of childhood cancer, lower than
intermediary nurses, data gathering was slow. anticipated scores on standardized measures of psy-
Research participation by some parents and chil- chological variables can be interpreted in several
dren was complicated by facts beyond their control: ways: (a) Resilience, coping skills, and support may
(a) Some children lived in foster care, necessitating lessen anxiety; (b) symptoms of anxiety may be denied
consent procedures that would have further extended (Kazak & Christakis, 1996); (c) children may act as
the data collection period, (b) other children had HIV- stoic good soldiers minimizing the severity of their
related cognitive deficits that precluded them from self-report symptoms (Kaplan, Busner, Weinhold, &
scoring in the age-appropriate range on the PPVT-R, Lenon, 1987); and (d) methodological difficulties of
indicating little likelihood that they would be able to self-report scales may preclude obtaining accurate
follow directions or read the STAIC questions, and data (Kazak & Christakis, 1996). In reference to the
(c) several children took psychotropic medications first interpretation, anxious symptoms that might be
that could have confounded data interpretation. found in this population may be ameliorated by the
Although we did not probe parents nor children increased attention and solicitude that parents and
who did not wish to participate, we were sensitive to health care providers offer them. For many, health care
the fact that this population had participated in other visits provide opportunities for stroking and praise
clinical trials, and may have been experiencing from nurses and physicians very committed to the
fatigue. Others may have had a healthy skepticism well-being of their clients. Indeed, the research team
about research and its potential to improve the child's was impressed with the depth of the compassionate
quality of life. care delivered by both, the parents/guardians and the
Among those who did participate, results suggested health care team, during the data collection period.
that "IT may be an effective tool for reducing state The level of awareness about having HIV infection
anxiety in children with HIV infection. The magnitude is unknown for this sample. However, many infected

school-age children are aware that they have the HIV
virus (Wiener, Moss, Davidson, & Fair, 1992). Despite
this knowledge, they tend to seek normalcy. Thus, the
only time they may think about their illness and con-
sider that they are sick may be during illness events.
Meanwhile, they may make effective use of defenses
such as denial, try to live their lives as children, play
with friends, go to school, and change and grow in
age-appropriate ways. On the other hand, some may
minimize the severity of their self-reported anxiety in
an effort to reduce complaining. There is a subtle
demand expectation in the social environments of
some HIV-infected children to minimize complaining.
Those children who know their diagnosis, or who are
at least suspicious that something is wrong, seriously
wrong with them, are aware that talking about their
concerns often raises parental/guardian anxiety.
Although not explicitly verbalized, those children who
live with their biological parents often recognize that
illness discussion compounds parental shame over
having HIV themselves and that mentioning their ill-
ness tends to call this shame to mind, and may even
confront parents with their own illness and potential
death. When children live in foster or adopted families,
they may not easily disclose their anxiety because they
understand that the parent does not want to acknowl-
edge that they know about their disease. Some parents
equate knowledge as harmful, fearing that knowledge
of HIV infection can do physical harm, for example,
"If my child knows, he will die."
In the current sample of children, anecdotal com-
ments made by children, parents, and RAs following
treatment suggest that there was some denial and a
covering over of concerns. For example, one child
asked whether the treatment could bring a mother back
from the dead or could help in communicating with a
dead person. Another child was described by the RA as
emotionally "shut down," and one parent reported that
her child had low self-esteem.
Self-report scales have the limitation in that they
reveal self-perceptions that are sometimes inflated and
inaccurate. It might have been illuminating to have
also tested trait anxiety, the more enduring aspect of
anxiety, rather than merely assessing state anxiety, a
more ephemeral reaction to a transitory event such as a
nursing intervention.
Ireland/ TherapeuticTouchWith HIV-InfectedChildren 75
Finally, whereas this sample was not staged accord-
ing to disease severity as determined by C D 4 % - - a
marker of disease progression--this was a generally
healthy group of children; 70% were reported by the
parent/guardian as asymptomatic. Bose et al. (1994)
found that low CD4% was one of the variables that
contributed to the presence of adjustment problems in
HIV-infected children. That is, the lower the CD4 lym-
phocyte count, the greater the disease severity. The
greater the disease severity, the more likely it is that the
child is exposed to stressors such as invasive medical
procedures, opportunistic infection, and debilitating
illness, all of which may effect the child's psychologi-
cal state.
Implications
The current pilot study suggests that there is reason
to pursue further research on the relationship between
TT and state anxiety among children with HIV infec-
tion, and it supports a body of evidence that this tech-
nique may help ameliorate or modify the experience of
those living with a chronic yet life-threatening illness.
TT may be at least as effective as other relaxation
therapies as a clinical strategy. However, the current
study is merely a beginning to the work that needs to be
done in psychosocial research related to care of chil-
dren with HIV infection. Given that the majority of
studies about their emotional needs are not empirical,
and that there is a paucity of literature identifying
interventions appropriate to those needs, "nurses 'do,'
using interventions based on research findings of other
chronic childhood illnesses" (Sherwen & Storm,
1996, p. 166). Well-designed intervention research is
vital to establishing appropriate care delivery and
improving the quality of life for the HIV-infected
child. Directions for future research should include the
following:
. measurement of the effect of stressors on anxiety
levels, both state and trait, and other psychologi-
cal variables, such as mood, with a larger sample;
. clinical trials that compare the efficacy of TT
with other complementary modalities and nur-
turing forms of touch, for example, the "nursing
back rub"/massage therapy (MT), in modifying
anxiety and mood;
76 JANAC Vol. 9, No. 4, July/August 1998
3. longitudinal studies that allow for serial data col-
lection points to extend knowledge about the
effects of such interventions on psychological
variables beyond a one-time administration or
dose;
4 investigations that evaluate the potential of nurs-
ing techniques such as TI" and MT to influence
immunosuppression as has been done with other
forms of stress reduction, for example, progres-
sive muscle relaxation, in HIV-infected adults;
and
5. a conceptual approach, for example, psychoneu-
roimmunology (PNI), that inherently integrates
psychological and physiological phenomenon,
thereby providing a biobehavioral framework in
which to examine the influence of anxiety,
depression, pain, and stressful situations on the
child's immune system, and the effect of relaxa-
tion therapies on these phenomenon.
In conclusion, a PNI framework could provide a
holistic paradigm in which to launch future research,
one that is consistent with the philosophical underpin-
nings of nursing science and one that could help
answer questions that emerge as children with HIV
disease live longer.
Acknowledgments. This research was supported
by the Rutgers College of Nursing Center for Health
Promotion Research, Rutgers University Research
Council Alpha Tau Chapter, Sigma Theta Tan Interna-
tional. The author thanks the staff, children, and fami-
lies of Incarnation Children's Center of Catholic
Home Bureau and Hew York Hospital-Cornell Medi-
cal Center Program for Children With AIDS who par-
ticipated in this study, and the research assistants,
Lousia Porrata, RN, MPH, and Allison McClughan,
who assisted with data collection.
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