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Measurement of Preoperative Anxiety in Young Children: Self-report Versus Observer-rated

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The utility of the self-report Children’s Anxiety and Pain Scale Anxiety subscale (CAPS-A) in comparison to the widely used, observer-rated Modified Yale Preoperative Anxiety Scale (mYPAS) in assessing anxiety in children undergoing day surgery procedures was examined. The CAPS-A test-retest reliability, concurrent validity with the Modified Yale Preoperative Anxiety Scale (mYPAS), and sensitivity to expected increases in anxiety at stressful times during the preoperative period were examined. Levels of observer-rated (mYPAS) and self-reported anxiety (CAPS-A) were obtained from 61 children (3 to 6years) undergoing day surgery procedures. The CAPS-A demonstrated adequate test-retest reliability. Concurrent validity between the CAPS-A and mYPAS scores was poor. The CAPS-A failed to show sensitivity to the expected increases in anxiety at stressful time-points. Thus, an alternative scoring strategy for the CAPS-A was proposed (i.e., child’s refusal to point was scored as high anxiety). Post-hoc analyses demonstrated good concurrent and adequate convergent validity with the alternative scoring strategy. KeywordsChildren-Anxiety-Measurement-Psychometric properties
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Measurement of Preoperative Anxiety in Young Children:
Self-report Versus Observer-rated
Kristi D. Wright & Allison Eisner & Sherry H. Stewart &
G. Allen Finley
Published online: 2 September 2009
#
Springer Science + Business Media, LLC 2009
Abstract The utility of the self-report Children s Anxiety
and Pain Scale Anxiety subscale (CAPS-A) in comparison
to the widely used, observ er-rated Modified Yale Preoper-
ative Anxiety Scale (mYPAS) in assessing anxiety in
children undergoing day surgery procedures was examined.
The CAPS-A test-retest reliability, concurrent validity with
the Modified Yale Preoperative Anxiety Scale (mYPAS),
and sensitivity to expected increases in anxiety at stressful
times during the preoperative period were examined. Levels
of observer-rated (mYPAS) and self-reported anxiety
(CAPS-A) were obtained from 61 children (3 to 6 years)
undergoing day surgery procedures. The CAPS-A demon-
strated adequate test-retest reliability. Concurrent validity
between the CAPS-A and mYPAS scores was poor. The
CAPS-A failed to show sensitivity to the expected increases
in anxiety at stressful time-points. Thus, an alternative
scoring strategy for the CAPS-A was proposed (i.e., childs
refusal to point was scored as high anxiety). Post-hoc
analyses demonstrated good concurrent and adequate
convergent validity with the alternative scoring strategy.
Keywords Children
.
Anxiety
.
Measurement
.
Psychometric properties
Preoperative anxiety in children is a common phenomenon.
In fact, up to 60% of children receiving surgery with
general anesthetic are anxious prior to the surgery in the
holding area and during the induction (Kain et al. 1996a).
For many children, being away from their familiar
environment coupled with the uncertainty about what may
happen during surgery can be very anxiety-provoking
(Kain e t al. 1996a, 1998). More specifically, younger
children (i.e., children aged 13 years) have been found to
be frightened of separating from their parents on the way
to the operating room (OR), whereas older children (i.e.,
children aged 412 years) have been found to have more
knowledge about what is happening and are m ore afraid of
the surgery itself (Kain et al. 1 998). Not only is
preoperative anxiety distressing for the child and his or
her parent(s), i t has also been associated with problems
pre- and post-surgery (e.g., Burton 1984;Kainetal.
1996b), including prolonged anesthetic induction (Kain et
al. 1999), and post-emergence distress (Kain et al. 2004).
In addition, the onset of m aladaptive post-operative
behavioural problems (e.g., general anxiety, nighttime
crying) have been reported to occur in up to 50% of
children undergoing general surgery procedures and to be
linked with the degree of preoperative anxiety (Kain et al.
1996b, 1999). Thus, interventions to reduce preoperative
anxiety are important for some children and families.
A reliable and valid method of anxiety measurement is
necessary to accurately assess a childs need for an anxiety-
reducing intervention and to assess the efficacy of any new
such interventions. There are a number of methods
employed to assess childhood anxiety in general, and
K. D. Wright (*)
Department of Psychology, University of Regina,
Regina, Saskatchewan, Canada, S4S 0A2
e-mail: kristi.wright@uregina.ca
S. H. Stewart
Department of Psychology, Dalhousie University,
Halifax, NS, Canada
S. H. Stewart
:
G. A. Finley
Department of Psychiatry, Dalhousie University,
Halifax, Nova Scotia, Canada
G. A. Finley
Department of Anesthesia, Dalhousie University,
IWK Health Centre,
Halifax, NS, Canada
A. Eisner
Factor-Inwentash Faculty of Social Work, University of Toronto,
Toronto, ON, Canada
J Psychopathol Behav Assess (2010) 32:416427
DOI 10.1007/s10862-009-9158-9
pediatric preoperative anxiety in particular (e.g., observer-
rated, self-report, parental report, physio logical measure-
ment). Within the context of the present study, two methods
of anxiety asses sment were of primary interest: child self-
reported and observer-rated.
Observer-rated Preoperative Anxiety Measures
There are numerous observer-rated measures of childhood
anxiety regarding medical procedures [e.g., Observational
Behavior Scale (Bradlyn et al. 1986); Behavioral Profile
Rating Scale-Revised (Gilbert et al. 1989); Observer
Ratings of Anxiety (LeBaron and Zelter 1984)]. However,
there are few that specifically assess anxiety associated with
anesthetic induction. The modified Yale Preoperative
Anxiety Scale (mYPAS; Kain et al. 1997) is a widely used
observer-rated measure designed to assess the anxious
distress exhibited by children during anesthetic induction
(e.g., Calipel et al. 2005 ; Golden et al. 2006; Kain et al.
1999, 2004; Patel et al. 2006; Vagnoli et al. 2005). The
mYPAS is comprised of five subscales [i.e., activity,
emotional expressivity, state of apparent arousal, vocalization,
and use of parent(s)]. The items for each category were
designed to be specific to behaviours that may occur precisely
at the time of a childs anesthetic induction as well those that
may take place in the holding ar ea. The mYPAS has
demonstrated good psychometric properties (e.g., Kain et al.
1997)(seeMeasures section for psychometric properties).
Self-report Preoperative Anxiety Measures
It has been sugges ted that anxiety is an internal state that
cannot be fully measured by an observer (Venham and
Gaulin-Kremer 1979). The refore, some argue that the best
way to assess anxiety is to ask the particular individual
about his or her anxiety. There are a number of ways to
measure general anxiety in children via self-report means.
For example, one could obtain an estimate of a childs
anxiety by having the chil d complete a questionnaire [e.g.,
Childrens Fear Survey Schedule-Revised (Barrios et al. 1983);
Childrens Manifest Anxiety Scale-Revised (Reynolds and
Richmond 1978); Fear Survey Schedule for Children-Revised
(Ollendick 1983); State Trait Anxiety Inventory for Children
(Spielberger 1973)]. There are a number of limitations to
employing a self-report questionnaire for the assessment of
anxiety, particularly in the preoperative setting. First, the child
must have acquired a particular reading level in order to
complete the measure; therefore, young children cannot be
assessed in this manner. Second, self-report questionnaires
typically take more time to complete than is available
preoperatively.
A self-report measure employing pictures may lend itself
well to both younger children and to testing situations
where there are time constraints. With this type of self-
report measure, the child is only required to point to the
face displaying the emotion that best represents how he or
she feels. One example of such a scale is the Venham
Picture Test (VPT; Venham et al. 1977). The VPT may be
less well suited for the surgery context as it takes more time
to complete than a briefer method such as the Childrens
Anxiety and Pain Scale (CAPS; Kuttner and LePage 1983),
to be described shortly. In addition, results from a pilot
study conducted in our lab (Finley et al. 2002) provided us
with some concerns regarding the face validity of the VPT
as a specific measure of anxiety as the measure depicts sad
and angry faces, as well as anxious faces.
The CAPS (Kuttner and LePage 1983
, 1989) is a self-
report measure of anxiety and pain. The CAPSAnxiety
scale (CAPS-A) is c ompr ised of fi ve gender neutr al
childrens faces progressively rangi ng from a face with a
neutral expression to one with a very anxious expression.
Children are required to point to the one face that best
expresses how they are presently feeling. The CAPS-A can
be quickly administered and therefore may be better suited
to the surgery context than the VPT. Further, the CAPS-A
has demonstrated good face validity (Kuttner and LePage
1983). However, the CAPS-A has yet to be tested for test-
retest reliability, concurrent validity, or sensitivity to the
effects of anxiety at induction.
The observer-rated mYPAS (Kain et al. 1997) is widely-
used in the day surgery setting to assess child anxiety.
However, it may be advantageous to have a reliable and
valid self-report, pictoral measure of preoperative anxiety
as these measures (e.g., CAPS-A) do not require time-
intensive training for observers nor necessitate a lengthy
administration. The latter characteristic alone makes the
CAPS-A an attractive option in the assessment of preoper-
ative anxiety within a busy day surgery depart ment. While
the mYPAS and CAPS-A measure anxiety in different ways
(i.e., observer- versus self-rated), one would expect to see
elevations in anxiety scores at anxiety-provoking time-
points during the day surgery process (e.g., separation from
parent and anesthetic induction ) across both measures.
Albeit, the level of elevation yielded by these two methods
may differ as a function of a more general concern of the
degree of agreement between childhood psychopathology
self-report measures and observer-rated measures. Within
the contex t of child assessment, agreement across inform-
ants (e.g., child, parent, teacher) often varies (De Los Reyes
and Kazdin 2005; Silverman and Ollendick 2005). In fact,
children tend to under-report psychopathology, when
compared with reports of parents and teachers (Holmbeck
et al. 2008). Further, it is also possible that observers (i.e.,
those employing the mYPAS) may not be able to observe
J Psychopathol Behav Assess (2010) 32:416427 417
all aspects of anxiety that are experienced internally and
therefore yield discrepant scores. Despite these discrep-
ancies, if the two measures are tapping the same construct
(i.e., preoperative anxiety), t here should be at least
moderate agreement.
The purpose of the present investigation was to examine
the utility of the mYPAS in comparison to a self-report
measure of anxiety, the CAPS-A. It was hypothesized that:
(1) CAPS-A should show a moderate correlation with
mYPAS scores (concurrent validity); (2) mYPAS and
CAPS-A scores should increase and decrease in a similar
manner across different testing points during the day
surgery process (convergent validity); and (3) both the
mYPAS and the CAPS-A should show stability over testing
phases (test-retest reliability). We reasoned that if the
CAPS-A did show good concurrent and convergent validity
with the mYPAS, and if it demonstrated good test-retest
reliability, then the measure could be used in future research
on preoperative anxiety and in selecting children for
anxiety reduction interventions.
Methods
Participants
Participants were 61 children aged three through six years
[35 males (mea n age = 5.04 years, SD=1.00 years) and 26
females (mean age = 5.41 years, SD=1.04 years)] sched-
uled for a day surgery procedure at the IWK Health Centre
(IWK), a tertiary care pediatric hospital in Halifax, Nova
Scotia, Can ada. The per cent ag es of types of su rgical
procedures utilized were as follows: Ear, nose and throat
(ENT; 80.3%), Urology (8.2%), General surgery (e.g.,
hernia repair; 8.2%), Gastroenterology (1.6%), and Plastics
(1.6%). Ethnicity in the sample was primarily Caucasian
(90.3%). Children were excluded if they had a history of
central nervous system disea se, psychiatric disease, liver
disease, renal disease, cancer, or neurological or cognitive
impairment or disease. Children with a history of gastro-
esophageal reflux disease were also excluded, as induction
was standardized to inhalation by mask (Cheong et al.
1999). The study was approve d by the IWK Health Centre
Research Ethics Board. The present study was a part of a
larger study examining the impact of parental presence and
absence on preoperative anxiety in children (Wright 2006)
1
.
Measures
Modified Yale Preoperative Anxiety Scale (mYPAS; Kain et
al. 1997) The mYPAS is an observer-rated scale designed
to measure a childs level of anxiety in the preoperative
setting (Kain et al. 1997). The mYPAS consists of 27 items
in five categories: activity (e.g., moving from toy to parent
in unfocused manner), vocalizations (e.g., whi mpering,
crying), emotional expressiveness (e.g., worried, sad, or
frightened eyes), state of apparent arousal (e.g., vigilant,
looking quickly all around), and use of parents (e.g.,
reaches out to parent). Each category is scored from 1 to
4, with the exception of vocalizations, which is scored from
1 to 6. Partial weights for each scale are calculated (Kain et
al. 1997 ) and then added together to obtain a total score for
each time point that ranges from 0 through 100. For
example, for two categories containing four and six items,
with a score of 1 in each category, the calculation is:
1=4 þ 1=6ðÞ100=2 ¼ total adjusted score. Good concur-
rent validity between mYPAS total score (using all five
categories) and self-reported state anxiety assessed by the
State Trait Anxiety Inventory for ChildrenState subscale
(Spielberger 1973) in children aged 512 (r=0.79) has been
demonstrated (Kain et al. 1997). Moreover, the mYPAS
shows good construct validity as scores have been shown to
increase from baseline to anesthetic induction in a previous
study by our group in children aged 46 (Finley et al.
2006). Finally, the mYPAS scales show good inter-rater
reliability with co effici ents ranging from r =0.730.91
(Kain et al. 1997). Since there was an inconsistency as to
the availability of a parent to the child throughout the five
time-points in the current study (i.e., only half of the
parents went in with the child during the induction), the use
of parents scale was dropped for the present study (i.e., 22
items across four categories were used; see Finle y et al.
2006). The first rater was present during the induction and
the second rater coded the mYPAS via videotape (the
second rater was blind to the investigation hypotheses). For
this investigation, intra-class correlations between the two
raters were computed for 20% of the participants (n=12
randomly selected) and yielded r=.89.
Childrens Anxiety and Pain Scale (CAPS; Kuttner and
LePage 1983, 1989) The CAPS is a self-report measure
developed to measure childrens level s of anxiety and pain
(Kuttner and LePage 1983). However, given the focus of
the present study, only the anxiety scale was administered
(i.e., CAPS-A). The CAPS-A scale consists of five
drawings of gender-neutral childrensfacesexhibiting
increasing levels of anxiety, beginning from a neutral
expression. The CAPS-A scores can range from 1 (neu-
tral)
5 (high anxiety). When tested on a group of 74
children aged 410 years, 77% were able to identify that
1
Analyses were completed to examine the utility of parental presence
in alleviating anxiety at anesthetic induction. No significant differ-
ences were observed in mYPAS scores across parental presence/
absence groups: [54.18(27.90) versus 52.75(24.27), respectively].
418 J Psychopathol Behav Assess (2010) 32:416427
the faces were c onveying the emotion of fear, providing
evidence of the scales good face validity (Kuttner and
LePage 1983). Data on test-retest reliability, concurrent
validity, and sensitivity to detecting the effects of anxiety at
induction are not available from previous research.
Procedure
When a child had been scheduled for a day surgery
procedure at the IWK and met all of the inclusion criteria,
an information package (i.e., information letter and consent
form) regarding the study was sent to the childs parents
one to two weeks prior to the scheduled surgery time. Three
days before the surgery day, a researcher contacted the
parent by telephone and asked if he or she was interested in
having his or her child participate in the study. If the parent
was willing for his or her child to participate, the researcher
arranged to meet with the parent(s) and child on the day of
surgery.
Approximately 90 min before the childs surgery,
parental written informed consent for the childs participa-
tion in the study, and the childs verbal assent was obtained.
The mYPAS and CAPS-A wer e completed at five intervals:
(1) ninety minutes before surgery (baseline 1), (2) five
minutes before surgery (baseline 2), (3) leaving the day
surgery room for the OR (stress 1), (4) when the anesthetic
mask was placed on the childs face (stress 2), and (5) when
the child returned to the day surgery area from the recovery
room (day surgery). The mYPAS was rated before the
CAPS-A was administered. The mYPAS was completed
first because we did not want the observer sratingtobe
influenced by the childs rating at t he same time point.
For the purposes of the present investigation, intervals
(3) and (4) were considered the most anxiety-provoking
of the various situations assessed and are thus referred to
as stress 1 and stress 2, respectively. The last tim e
point [i.e., (5)] was referred to as day surgery.Once
the child returned to the day surgery area from the
recovery room, the researcher met with the child and
parent(s) and the child was given a sheet of stickers as a
token of thanks for their participation.
Results
Descriptive Statistics
Mean, standard deviation (SD), and range of mYPAS and
CAPS-A scores across the five time-points are presented in
Table 1. A total of 12 children did not point to faces on the
CAPS-A at one or more time-points (please see Feasibility
section for further description). These children were not
included in the main analyses and the implic ations of this
issue are explored in the Feasibility Section of the results.
In order to investigate whether demographic information
influenced mYPAS a nd CAPS-A scor es, a series of
univariate analyses of variance (ANOVAs) were performed
for the two stressful time-points (i.e., stress 1 and stress 2).
The focus was placed upon these two stressful time-points
as these time-points are of most clinical interest and in an
effort to reduce the overall number of analyses. The results of
these analyses indicated that mYPAS scores at stress 1 did
not differ significantly as a function of gender, F[1,59]=
0.24, ns, type of surgery, F[1,59]=0.27, ns, or previous
surgery, F[1,59]=0.01, ns. The results similarly indicated
that mYPAS scores at stress 2 did not differ significantly as
a function of gender, F[1,59]=0.04, ns, type of surgery, F
[1,59]=0.63, ns, or previous surgery, F[1,59]=0.35, ns.
Results also indicated that CAPS-A scores at stress 1 did
not differ significantly as a function of gender, F
[1,54]=
1.47, ns, type of surgery, F[1,54]=0.29, ns, or previous
surgery, F[1,54]=0.27, ns. Similarly, CAPS-A scores at
stress 2 did not differ significantly as a function of gender,
Table 1 Descriptive statistics for mYPAS and CAPS-A scores across five time-points
Assessment time-point mYPAS CAPS-A CAPS-A
Mean(SD) Median Score range Mean(SD) Mean(SD) Median Score range
RS
baseline 1 27.30(6.24) 23.00 2348 1.38(0.77) 1.38(0.76) 1.00 14
baseline 2 27.06(6.60) 23.00 2352 1.17(0.42) 1.30(0.80) 1.00 15
stress 1 32.89(16.66) 27.00 2395.75 1.43(0.83) 1.72(1.27) 1.00 15
stress 2 53.45(25.91) 45.75 23100 1.48(0.83) 2.00(1.47) 1.00 15
day surgery 33.25(12.92) 33.25 2393.75 1.52(1.14) 1.80(1.46) 1.00 15
CAPS-A Child Anxiety Pain Scale-Anxiety subscale (Kuttner and LePage 1983); mYPAS modified Yale Preoperative Anxiety Scale (Kain et al.
1997); baseline 1 = child in the waiting room; baseline 2 = 5 min prior to leaving the day surgery room; stress 1 = leaving day surgery for OR;
stress 2 = anesthetic mask placement; day surgery = child returned to day surgery; CAPS-A total score ranges from 1 to 5; mYPAS total score
ranges from 23 to 100. RS = CAPS-A alternative scoring employed
J Psychopathol Behav Assess (2010) 32:416427 419
F[1,50]=0.04, ns, type of surgery, F[1,50]=0.87, ns, or
previous surgery, F[1,50]=0.31, ns.
In order to examine whether age had a significant
association with anxiety scores, a bivariate correlation was
computed between age and mYPAS and CAPS-A scores at
the two stressful time-points. No significant correlations
were found between age and mYPAS scores, (r(59)=.01
[stress 1] and r(59)=.14 [stress 2], respectively, both ns)
or CAPS-A scores (r(54)=.10 [stress 1] and r(50)=.13
[stress 2], respectively, both ns). The non-significant
correlations suggest that mYPAS and CAPS-A scores do
not vary as a result of age, at least within the age range
tested in the present study. Together, this set of analyses
suggest that the outcome measures were not impacted by
any of the measured demographic or surgery variables.
Examination of the Psychometric Properties of the CAPS-A
Test-retest Reliability of the CAPS-A No previous data was
available on the test-retest reliability of the CAPS-A. In
order to examine the test-retest reliability of the CAPS-A,
bivariate correlations were computed between the
CAPS-A scores across all five the time-points. The
significant correlations are discussed next. A significant
relationship was observed between baseline 1 and stress
1(r(54)=.41, p<.01), baseline 2 and stress 1 (r(52)=.40,
p<.01), and stress 1 and stress 2 (r(49)=.36, p<.05).
However, when a Bonferroni correction was used, these
correlations were no longer significant. Similarly, test-
retest reliability of the mYPAS over the same time-points
was not particularly high. The significant correlations are
discussed next. A significant relationship was observed
between observer-rated anxiety at baseline 1 and baseline
2(r(58)=.34, p<.01), baseline 2 and stress 1 (r(59)=.32,
p<.05), and stress 1 and stress 2 (r(59)=.34, p<.01).
However, when a Bonferroni correction was used, these
correlations were no longer significant.
Concurrent Validity of the CAPS-A In order to assess the
concurrent validity of the CAPS-A, it was compared with
thewidelyusedobserver-ratedanxietymeasure,the
mYPAS. In order to do so, bivariate correlations were
computed between CAPS-A and mYPAS at each of the five
time points. Results showed no significant correlations
between measures, w ith two exceptions. A significant
relationship was observed between CAPS-A and mYPAS at
day surgery (r(54)=.40, p =.003). Whe n a Bonferr oni
correction was used, this correlation no longer remained
significant . A si gnificant relationsh ip was obs erved
between CAPS-A at stress 2 and mYPAS baseline 1 (r
(59)=.28, p=.044). When a Bonferroni correction was
used, this correlation was no longer significant. Further-
more, bivariate correlations were also computed between
CAPS-A and mYPAS change scores (i.e., change from
baseline 1 to the two stressful time points on each of the
two measures). No significant correlations were revealed
(r(54)= .12 [stress 1] and r(50)=
.07 [stress 2], respec-
tively, both n s). Overall, these results suggest poor
concurre nt v ali dity of the CAPS-A in terms of rel ati ons
with the wel l-established mYPAS.
In order to further examine the association between the
mYPAS and CAPS-A, it would be important to determine if
CAPS-A scores at baseline are predictive of mYPAS scores
during anxiety provok ing or stressful time-points (i.e.,
stress 1 and 2). In other words, are children who are
identified as anxious on the CAPS-A on the day of surgery,
but prior to the more stressful surgery events, those who
also display the most anxious reactivity at the more
stressful time points such as leaving day surgery for the
OR or anesthetic induction? A direct entry multiple
regression procedure was utilis ed in order to determine
whether CAPS-A baseline 1 or 2 predicted a unique amount
of variance in the criterion variables (i.e., mYPAS stress 1
and stress 2, respectively). Four regression analyses were
computed (two with mYPAS stress 1 as the criterion
variable and two with mYPAS stress 2 as the criterion
variable) with either CAPS-A baseline 1 or baseline 2
entered into the regression equati on. With respect to the
predictive utility of the CAPS-A baseline 1 to mYPAS
stress 1, the R
2
indicated that the amount of variance
accounted in mYPAS stress 1 was 0.1% and the model was
not significant, F[1,59]=0.19, ns. Wit h respect to the
predictive utility of CAPS-A baseline 2, the R
2
indicated
that the amount of variance accounted in mYPAS stress 1
was 1.2% and the model was not signifi cant, F[1,57]=0.67,
ns. With respect to the predictive utility of CAPS-A
baseline 1 to mYPAS stress 2, the R
2
indicated that the
amount of variance accounted in mYPAS stress 2 was 0.1%
and the model was not significant, F[1,59]=0.04, ns. With
respect to the predictive utility of CAPS-A baseline 2, the
R
2
indicated that the amount of variance accounted in
mYPASstress2was2.2%andthemodelwasnot
significant, F[1,57]=1.23, ns. Results indicate that neither
CAPS-A baseline 1 and 2 are useful predictors of anxiety
measured at mYPAS stress 1 (leaving day surgery for OR)
or 2 (anesthetic induction).
In order to assess the convergent validity of the CAPS-
A, it was important to determine whether both measures
increased and decreased in the same way and whether the
CAPS-A (like the mYPAS) was sensitive to expected
increases from baseline in response to the two stressful
time-points. To assess this, a 2 (measure: mY PAS vs.
CAPS-A) × 5 (assessment time: baseline 1 vs. baseline 2
vs. stress 1 vs. stress 2 vs. day surgery) repeated measures
ANOVA was calculated. Results showed main effects both
for measure, F[1,42]=763.47, p<.001, and time-point,
420 J Psychopathol Behav Assess (2010) 32:416427
F[4,168]=20.52, p<.0 01, as well as a measure × time-point
interaction, F[4,168]=20.68, p<.001. Simple effects anal-
yses were performed in order to further examine the
measure × time interaction. Specifically of interest was
the simple effect of time for each measure separately.
Results demonstrated no significant simple main effect of
time for the CAPS-A, F[4,172]=1.38, ns, indicating that
the self-report measure failed to show sensitivity to the
expected increases in anxiety at the two stressful time-
points. In contrast, there was a highly significant simple main
effect of time for the mYPAS, F[4,216]=30.43, p<.001. To
further examine the simple main effect of time for the
mYPAS, dependent sample t-tests were performed between
means at successive time-points to determine where the
significant differences lay. There was a significant increase in
mYPAS scores from baseline 2 (5 min before leaving day
surgery) to stress 1 (leaving day surgery for OR), t[58]=2.52,
p<.05, stress 1 (leaving day surgery for OR) to stress 2
(anesthetic induction), t[59]=6.52, p<.001, and a significant
decrease from stress 2 (anesthetic induction) to day surgery,
t[56]=5.30, p<.001. There was no significant change from
baseline 1 (waiting room) to baseline 2 (5 min before leaving
day surgery).
Both correlational and repeated measures ANOVA
analyses were re-run by comparing two groups: younger
children and older children. The rationale for this analysis
was that the CAPS-A was designed for children aged four
years or older and since the present sample included
children aged three years, it was of interest to examine
whether the inclusion of younger children in the present
study adversely influenced the psychometric properties of
the CAPS-A. Participants were catego rized in the younger
group if they were three or four years old (n=26)
2
and
participants were categorized in the older group if they
were five or six years old (n=35). Then , bivariate
correlations were computed between CAPS-A and mYPAS
at the two stressful time-points separately for the younger
and older groups. Results showed no significant correla-
tions between measures for both the younger (r(22)=.04
[stress 1] and r(19)=.31 [stress 2], respectively, both ns)
and older (r(30)=.20 [stress 1] and r(29)=.06 [stress 2],
respectively, both ns) groups, suggesting poor concurrent
validity in both age groups. Furthermore, bivariate correla-
tions were computed between the CAPS-A and mYPAS
change scores (i.e., change from baseline 1 to the two
stressful time-points). Results showed no significant corre-
lations between measures for both the younger (r(22)=.24
[stress 1] and r(19)=.19 [stress 2], respectively, both ns)
and older (r(30)=.10 [stress 1] and r(29)=.05 [stress 2],
respectively, both ns) g roups, again suggesting poor
concurrent validity in both age groups.
Results from a 2 (age group: younger vs. older) × 2
(measure: mYPAS vs. CAPS-A) × 5 (assessment time:
baseline 1 vs. baseline 2 vs. stress 1 vs. stress 2 vs. day
surgery) repeated measures ANOVA showed main effects
both for measure, F[1,41]=738.05, p<.001, and time-point,
F[4,164]=19.93, p<.001, but not for age group. The only
interaction observed was the previously-reported measure ×
time-point interaction, F[4,164]=20.2 5, p<.00 1. These
analyses are consistent with the findings reported above
and demonstrate that the CAPS-A was no more valid (in
terms of sensitivity to the expected increases in anxiety at
the more stressful time-points) for the older than for the
younger children in the study.
Feasibility Finally, the feasibility of employing the CAPS-
A in the day surgery process was examined, including at
the point of anesthetic induction. In order to do so, the
frequency of children that refused to point to a face at the
two stressful time-points was exami ned. In total, 8.2%
(n=5) of the children did not point to a face prior to going
into the OR (stress 1) and 14.8% (n=9) of the children did
not point to a face at anesthetic induction (stress 2). In
contrast, no children refused to point during baseline 1
andonly3.3%(n=2) of the children refused to point at
baseline 2. A relatively large number of children refused
to point at return to day surgery (i.e., day surgery; 8.3% or
n=5); however, it was not unusual for the children to not
feel entirely like themselves following surgery (e.g., sore,
sleepy, groggy) and some children may not have pointed
for these reasons. Further, this study examined whether the
pointing varied as a function of age. Results from a one-
tailed t-test (pointers vs. non-pointers at the stress 1)
revealed that age did not significantly impact pointing at
stress 1, t[59]= 2.21, p=.44
3
. However, results from a
one-tailed t-test (pointers vs. non-pointers at the stress 2)
revealed that age did significantly impact pointing at stress
2, t [59]=1.81, p=.04
4
. Those who refused to point at the
stress 2 were significantly younger than those who agreed
to point [mean age for non-pointers = 4.60 (SD=0.81);
mean age for pointers = 5.30 (SD=1.05)].
2
There were too few three year olds to permit separating out their data
relative to the four-six year olds. Thus, the comparison was completed
between three-four year olds and five-six year olds.
3
Due to the different group sizes it was necessary to test for violations
to the assumption of homogeneity of variance. This test was
completed and the results suggested that the assumption was not
violated.
4
Due to the different group sizes it was necessary to test for violations
to the assumption of homogeneity of variance. This test was
completed and the results suggested that the assumption was not
violated.
J Psychopathol Behav Assess (2010) 32:416427 421
Finally, an important question to address was whether
the children who refused to point to a face had higher
observer-rated anxiety than those who completed the task
by pointing. Results of a univariate ANOVA (pointers vs.
non-pointers at stress 1) demonstrated a significant effect of
pointing, F[1,59]=31.90, p<.001,
5
in that children who
refused to point to a face had a significantly higher
observer-rated score of anxiety at stress 1 [mean mYPAS
score for non-pointers = 65.80 (SD=28.31); mean mYPAS
score for pointers = 29.95 (SD=11.72)]. Results of a
univariate ANOVA (pointers vs. non-pointers at stress 2),
with age used as a covariate, demonstrated a significant
effect of pointing, F[1,58]=12.84, p<.001,
6
in that children
who refused to point to a face had a significantly higher
observer-rated score of anxiety at stress 2 [mean mYPAS
score for non-pointers = 80.78 (SD=14.99); mean mYPAS
score for pointers = 48.7 (SD=24.5)]. This is concerning
because it suggests that we are missing self-report data for
the very children who may be most anxious at induction.
Post-hoc Investigation of Revised CAPS-A Scoring
Our results demonstrated t hat a certain proportion of
children refused to point to any of the CAPS-A faces fairly
often at the two stressful time points (8.2% of time for stress 1
and 14.8% of the time for stress 2). In turn, the non-pointing
children had significantly higher mYPAS scores at stress 1
and 2. These results appear to suggest that children who did
not point were experiencing high levels of stress and, as a
result, chose to not point. Given this possibility, we devised an
alternative way to score non-pointing. Specifically, we
proposed that non-pointers (across all time-points) should
receive a maximal CAPS-A score (i.e., 5). We assessed the
utility of this new scoring strategy by completing the
aforementioned analyses a subsequent time.
Test-retest Reliability of the CAPS-A Test-retest reliability
of the CAPS-A was re-examined. Bivariate correlations
were computed between the CAPS-A scores across all five
the time-points. A significant relationship was observed
between baseline 1 and stress 1 (r(59)=.41, p<.001) and
stress 1 and stress 2 (r(59)=.43, p<.001). No association
was observed between baseline 2 and stress 1 as seen
before. However, when a Bonferroni correction was used,
these correlations were no longer significant.
Concurrent Validity of the CAPS-A Bivariate correlations
were again computed between CAPS-A and mYPAS at
each of the five time points (see Table 2). In contrast to the
previously-reported results, these analyses yielded signifi-
cant correlations between measures. Specifically, significant
relationships were observed between CAPS-A and mYPAS
across four of the five time-points, with the exception of
baseline 1. When a Bonferroni correction is used, two of
the four aforementioned correlations remained significant.
The association between CAPS-A and mYPAS at baseline
2 and day surgery were no longer significant following the
application of the Bonferroni correction. Furthermore,
bivariate correlati ons were also computed between CAPS-
A and mYPAS change scores (i.e., change from baseline to
the two stressful time points on each of the two measures).
Significant correlations were revealed (r(59)=.35 [stress 1]
and r(59)=.37 [stress 2], respectively, both p<.01). Find-
ings remained significant when Bonferroni correction was
applied. These results are suggestive of good concurrent
validity, in contrast to initial findings.
The predictive utility of the CAPS-A scores at baseline
were re-examined. The aforementioned four regression
analyses were re-run using the same regression procedure.
No significant change in results was observed with the first
three analyses. In contrast to initial results, this latter analysis
indicates that CAPS-A baseline 2 is the only significant
predictor of anxiety measured at mYPAS stress 2 (anesthetic
induction). Specifically, with respect to the predictive utility
of CAPS-A baseline 2, the R
2
indicated that the amount of
variance accounted in mYPAS stress 2 was 6.6% and the
model was significant, F[1,59]=4.19, p<.05.
The 2 (measure: mYPAS vs. CAPS-A) × 5 (assessment
time: baseline 1 vs. baseline 2 vs. stress 1 vs. stress 2 vs.
day surgery) repeated measures ANOVA were also re-run.
Results were is sharp contrast to initial findings. Results
again showed main effects both for measure, F[1,54]=
820.33, p<.001, and time-point, F[4,216]=31.34, p<.001,
as well as a measure × time-point interaction, F[4,216]=
31.99, p<.001. Simple effects analyses were performed in
order to further examine the measure × time interaction.
The simple effect of time for each measure was examined
separately (only the CAPS-A results are reported below as
results from mYPAS are identical to those initially
reported). Results demonstrated significant simple main
effect of time for the CAPS-A, F[4,236]=3.70, p<.01. To
further examine the simple main effect of time for the CAPS-
A, dependent sample t-tests were performed between means
at successive time-points to determine where the significant
differences lay. There was a significant increase in observer
scores from baseline 2 (5 min before leaving day surgery) to
stress 1 (leaving day surgery for OR), t[59]=2.03, p<.05. No
significant changes were observed from (1) baseline 1
(waiting room) to baseline 2 (5 min before leaving day
6
Due to the different group sizes it was necessary to test for violations
to the assumption of homogeneity of variance. This test was
completed and the results suggested that the assumption was not
violated.
5
Due to the different group sizes it was necessary to test for violations
to the assumption of homogeneity of variance. This test was
completed and the results suggested that the assumption was not
violated.
422 J Psychopathol Behav Assess (2010) 32:416427
surgery), (2) stress 1 (leaving day surgery for OR) to stress 2
(anesthetic induction), or (3) stress 2 (anesthetic induction) to
day surgery. These results suggest that CAPS-A was
somewhat sensitive to expected increases in anxiety, at least
from baseline 2 to stress 1.
Both correlational and repeated measures ANOVA anal-
yses were re-run by comparing two groups: younger children
and older children. Results showed significant correlations
between measures for both the younger (r(24)=.39 [stress 1],
p<.05 and r(24)=.60 [stress 2], p<.01, respectively) and
older only at stress 1 (r(33)=.59, p<.001). The association
between CAPS-A and mYPAS at stress 2 approached
significance for the older children (r(33)=.32, p=.057).
Results suggest fairly good concurrent validity in both age
groups. However, when a Bonferroni correction was used,
these correlations were no longer significant. Furthermore,
bivariate correlations were computed between the CAPS-A
and mYPAS change scores (i.e., change from baseline 1 to
the two stressful time-points). Results showed no significant
correlation between measures for the younger group at stress
1(r(24)=.12). However, a significant correlation was
observed between the measures for the younger group at
stress 2 (r(24)=.44, p<.05). The correlation was no longer
significant after applying the Bonferroni correction. A
significant correlation was observed at stress 1 for the older
group (r(33)=.65, p<.001), while no significant association
was observed at stress 2 (r(33)=.29, ns). This correlation
remained significant after applying the Bonferroni correc-
tion. The latter findings suggest mixed concurrent validity in
both age groups, at least for the change scores.
Results from a 2 (age group: younger vs. older) × 2
(measure: mYPAS vs. CAPS-A) × 5 (assessment time:
baseline 1 vs. baseline 2 vs. stress 1 vs. stress 2 vs. day
surgery) repeated measures ANOVA showed main effects
both for measure, F[1,53]=798.67, p<.001, and time-point,
F[4,212]=30.93, p<.001, but not for age group. The only
interaction observed was the previously-reported measure ×
time-point interaction, F[4,212]=31.4 5, p<.00 1. These
analyses are consistent with the findings reported above
and demonstrate that the CAPS-A with revised scoring
appears similarly valid (in terms of se nsitivity to the
expected incre ases in anxiety at the more stressful time-
points) for the younger and older children in the study.
Discussion
Accurate measur eme nt o f anxiety is important in the
pediatric day surgery setting as high levels of anxiety can
lead to adverse consequences both during surgery (e.g., at
anesthetic induction) and post-surgery (e.g., Kain et al.
1999). In order to determine if an anxiety-reducing
intervention (e.g., preoperative sedative medication, paren-
tal presence during anesthetic induction) is appropriate to
employ with a given child, a psychometrically-sound
measure of the childs level of anxiety is required. Although
the mYPAS offers a valid observer-rated measure of
anxiety, it is also important to have a valid self-report
measure of anxiety, as self-report measures require less
training for staff and are less subject to inter-observer
variability. The ideal self-report measure would be quick
and easy to administer, given the time-constraints associat-
ed with the day surgery setting, such as the CAPS-A.
Examination of demographic statistics sugges ted that
childs sex, type of surgery, and whether or not he/she had
previously undergone a surgical procedure, did not signif-
icantly impact the childs level of anxiety. In addition,
ratings of anxiety did not differ as a function of age.
Since leaving the day surgery room for the OR and the
anesthetic induction itself are both potentially stressful
events in the day surgery context, a measure of anxiety
should reflect similar ratings at these two time-points.
Children who score high at one of these stressful time-
Table 2 Correlations between CAPS-A and mYPAS across five time-points with revised CAPS-A scoring
mYPAS mYPAS mYPAS mYPAS mYPAS
baseline 1 baseline 2 stress 1 stress 2 day surgery
CAPS-A baseline 1 .065 .291* .085 .015 .152
CAPS-A baseline 2 .019 .333** .029 .140 .082
CAPS-A stress 1 .017 .143 .486*** .298* .022
CAPS-A stress 2 .016 .257* .212 .457*** .176
CAPS-A day surgery .153 .012 .256 .140 .338*
CAPS-A Child Anxiety Pain Scale-Anxiety subscale (Kuttner and LePage 1983); mYPAS modified Yale Preoperative Anxiety Scale (Kain et al.
1997); baseline 1 = child in the waiting room; baseline 2=5 min prior to leaving the day surgery room; stress 1 = leaving day surgery for OR;
stress 2 = anesthetic mask placement; day surgery = child returned to day surgery. Following Bonferroni correction, correlations between CAPS-A
and mYPAS at stress 1 and 2 remain significant
*p=.05, **p=.01, ***p=.001
J Psychopathol Behav Assess (2010) 32:416427 423
points would be expected to score high at the other stressful
time-point. Given that little is known about the psychomet-
ric properties of the CAPS-A, one of the objectives of this
investigation was to examine whether the CAPS-A is a
reliable measure of preoperative anxiety in children aged
three to six years. Therefore, we were interested whether
CAPS-A scores at the two stressful time-points (stress 1
and stress 2) would be associated. Bivariate correlations
were compute d across all five time-points. Significant
correlations were observed between baseline 1 and stress
1, baseline 2 and stress 1, and stress 1 and 2. Analyses
revealed that indeed scores at these two stressful time-
points were significantl y c orrelated with one another,
although only moderately so. However, these correlations
were no longer significant once the Bonferroni correction
was applied. This is an important finding since previous
research (i.e., Kuttner and Lepage 1983) had yet to examine
this aspect of the CAPS-As psychometric properties.
Similar findings were yielded in regards to the test-retest
reliability of the mYPAS.
It was also hypothesized that such ratings should show
moderate correlations with the well-validated observer-
rated measure of anxiety, the mYPAS (concurrent validity),
in addition to increasing and decreasing in a similar manner
to the mYPAS across different testing points during the day
surgery process (convergent validity). However, findings
from our initial analyses did not support these hypotheses.
For example, a low and non-significant degree of correla-
tion was observed between the self-report and observer-
rated measures of anxiety at both stressful time-points.
CAPS-A and mYPAS scores were significantly correlated
at the time-point when the child returned to the day surgery
room following surgery. Albeit, when a Bonferroni correc-
tion was used, this correlation was no longer significant.
Baseline 1 and 2 CAPS-A scores were also not found to be
predictive of mYPAS stress 1 or stress 2 scores, suggesting
the CAPS-A would not be a useful predictor of observable
child anxiety at stressful times in surgery if the CAPS-A
were to be routinely administered prior to these stressful
periods. In addition, the CAPS-A scores did not vary
significantly across the five study time-points and thus the
measure failed to demonstrate sensitivity to the expected
increases in anxiety at the two stressful time-points, relative
to baseline. In contrast, the mYPAS scores did vary
significantly across time-points, and specifically showed
an increase from baseline 1 to stress1, stress 1 to stress 2,
then a decrease in anxiety from stress 2 to day surgery. This
sensitivity of the mYPAS was expected and is consistent
with previous results from independent samples (e.g.,
Finley et al. 2006; Kain et al. 1998).
We entertained the possibility that the lack of concurrent
validity of the CAPS-A with the mYPAS may have been
due in part to younger children (i.e., three years olds) not
understanding what was being asked of them, as the CAPS-
A was originally desig ned for children 4 years or older.
Further analyses revealed that when the ratings of younger
(i.e., three-four year olds) and older (i.e., five-six year olds)
children were isolated, the CAPS-A ratings did not
converge with those of the mYPAS even in the older
children. However, it should be noted that the sample size
in this study was not large enough to isolate 3 year olds and
compare them to the rest of the children. Nonetheless, these
findings do not suggest that the validity of the CAPS-A
would be improved based on testing only children aged five
or older.
It was also important to assess whether it is even feasible
to use a measure such as the CAPS-A in the pediatric day
surgery context. In order to evaluate this issue, this study
examined the frequency of a childs unwillingness or
inability to point to a face at the two time-points that were
considered most likely to be stressful for the child. The
results showed that refusal to point to any of the faces
occurred fairly often at the two stressful time points (8.2%
of time for stress 1 and 14.8% of the time for stress 2).
These statistics suggest that approximately 815 children
out of 100 children tested with this measure will demon-
strate difficulty completing this measure at these stressful
time-points. These results raise the issue of the feasibility of
using this measure in the preoperative context. Further,
results indicated that the children who did not point to a
face at stress 2 (anesthetic induction) were significantly
younger than the pointers. One possible explanation for this
effect is that older children tend to have more understand-
ing of their surroundings and what is happening than
younger children (Kain et al. 1998), and that the anxiety
and the OR environment could impede the younger child-
rens willingness to reflect on how they are feeling. The
present results appear consistent with findings from
Stanford et al. (2006) who examined young childrens
ability to use the Faces Pain Scale-Revised (FPS-R; Hicks
et al. 2001) in a sample of 112 three to six year olds. Their
findings suggested that a substantial number of young
children experienced difficulty using the FPS-R in response
to hypothetical vignettes depicting pain scenarios common
in childhood. Results suggested that five- and six-year-old
children were significantly more accurate in using the FPS-
R than four-year-olds and five-year-olds wer e significantly
more accurate than three-year-olds. That being said, over
half of the six-year-olds still demon strated difficulty using
the FPS-R (Stanford et al. 2006).
Even more importantly, results from the present study
further demonstrated that children who refused to point to a
face during the induction had significantly higher observer-
rated anxiety than those children who were compliant about
pointing. This was unfortunate as it indicates that the
CAPS-A may have limited feasibility, at least when scored
424 J Psychopathol Behav Assess (2010) 32:416427
as originally conceived, amongst those children who have
the greatest need for anxiety assessment.
Given poor concurrent and convergent validity, coupled
with the finding that non-pointing children had significantly
higher anxiety than pointing children, we wondered if we
could revise the CAPS-A coding system to include the
coding of non-pointing as an important indicator of the
presence of child anxiety. Thus, we proposed that non-
pointers receive a maximal CAPS-A score (i.e., 5). We
assessed the utility of this new scoring strategy by
completing our initial analyses a subsequent time. Overall,
our post-hoc analyses painted a somewhat different picture
of the CAPS-A. With respect to the test-retest reliability of
the CAPS-A, significant relationships were observ ed (prior
to stringent Bonferroni correction) between baseline 1 and
stress 1 and stress 1 and 2 (two most stressful time-points).
No association was observed between baseline 2 and stress
1 as seen before; however, a similar relationship was
observed between stress 1 and 2. Albeit, these correlations
are no longer significant once the Bonferroni correction is
applied. We also observed good concurrent validity. In
contrast to the initial results obtained when using the
traditional CAPS-A scoring, these new analyses yielded
the hypothesized significant moderate associations between
the CAPS-A and mYPAS across four of the five time-
points. Even when a stringent Bonferroni correction was
used, two of the four aforementioned correlations remained
significant. In terms of predictive utility of the CAPS-A, we
found that the revised Baseline 2 CAPS-A score was a
significant predictor of anxiety measured at mYPAS stress
2 (anesthetic induction). And additionally, revised CAPS-A
scores did significantly vary across the day surgery process
with a significant increase observed from baseline 2 to
stress 1. Thus, the CAPS-A measure showed some
sensitivity to the expected increases associated with anxiety
induction when using the new scoring.
It appears that this alternative scoring strategy [i.e.,
assigning a maximal CAPS-A score (score of 5) to non-
pointing] may have successfully addressed the observed
discrepancy across CAPS-A and mYPAS scores. While the
convergence is not perfect, the findings from our post-hoc
analyses suggest that the CAPS-A should not be ruled out as
a measure that has potential use in the preoperative setting.
Although this investigation yielded a number of inter-
esting findings, there are a number of limitations that
deserve attention. First, this study used an observer-rated
measure of anxiety as the standard against which to assess a
self-report measure. There are two potential issues that
should be noted here. It may be the case that these two
types of measures tap into different aspects of anxiety
(Kuttn er and L ePa ge 1989). Employing the proposed
alternative scoring strategy improved the association be-
tween the two measures, albeit the association remained
low-to-moderate in magnitude. If these two measures in
fact tap different aspects of the anxiety experienced they
could be lower-order components of the higher-order
construct of anxiety given the o bserved low-moderate
correlation. It is possible that observers may not be able
to observe all aspects of anxiety that are experienced
internally. Additionally, the strength of association between
the mYPAS and CAPS-A may be impacted by the notion
that children tend to under-report psychopathology, when
compared to other informants such as parents and teachers
(Holmbeck et al. 2008).
A second limitation to consider is with respect to the
faces depicted on the CAPS-A. A general observation is
that the faces depicting high levels of anxiety are somewhat
frightening in and of themselves. Although there is no
evidence that the childs responses were impacted in this
fashion, as they were not questioned about their feelings
toward the faces, it is possible. Additionally, frightening
faces may have been avoided by anxious children. Re-
evaluation of the faces themselves and possibly making
some adjustments may improve the utility of the CAPS-A
in this setting. The latter may be achieved by asking
children about their reactions to the faces depicted in the
CAPS-A under various conditions varying in stress levels.
A third limitation involves the instructions associated
with the administration of the CAPS-A. It is conceivable
that a child may have misinterpreted the question asked (i.e.,
Please point to the face that shows how you feel) and
chose the face that physically resembled himself or herself
the most (rather than reflecting his or her current emotional
state the most). We did not evaluate this possibility directly.
However, if this notion is plausible, we should have been
more likely to observe younger children misinterpreting
instructions resulting in lower validity than among older
children. Our results did not support this trend, as the
CAPS-A was no more valid for older children than for
younger children in our sample.
Fourth, it is also important to note that a larger sample
size would have been preferable. Subsequent research
should seek to re-examine the psychometric properties of
the CAPS-A with a larger sample. A larger samp le would
allow for better comparison across age groups and allow us
to better examine any developmental effects in the
measurement of child anxiety employing the CAPS-A.
Fifth, these results may have also been affected by range
restriction. Examination of the CAPS-A means in Table 1
demonstrates that most children selected the first face
(corresponding to a score of 1) across the measurement
time-points, and this remained the same when the alterna-
tive scoring strategy was employed. That being said, the
scores did range from 1 to 5 (the largest range possible).
Subsequent research employing a larger sample size wi ll
allow this issue to be evaluated further.
J Psychopathol Behav Assess (2010) 32:416427 425
Finally, in completi ng the observer-rated anxiety mea-
sure (mYPAS), our first rater was not blind to the study
hypotheses. It is possible that the mYPAS may have been
sensitive to the expected increases and decreases over time
because the rater was not hypothesis-blind and her scores
may have been subtly influenced by her expectations of
increases at stress 1 and 2 and of decreases at return to day
surgery room following surgery. In contrast, there was no
possible experimenter bias in the children s ratings. This
concern does not appear warranted, however, as a
hypothesis-blind second rater showed excellent conver-
gence of mYPAS ratings with the first rater when scoring a
random sub-sample of participants.
Overall, the results suggest that the CAPS-A may be
able to appropriately measure child anxiety in the context of
the day surgery experience when the proposed alternative
scoring strategy is employed [non-pointers receive a
maximal CAPS-A score (i.e., 5)], at least when compared
to the mYPAS. Given that this is a preliminary investigation
of the validity of the CAPS-A, a subsequent investigation
comparing the CAPS-A to another pictorial self-report
measure of anxiety (e.g., VPT) in a larger sample with equal
numbers of participants across age groups (i.e., three-, four-,
five-, and six-year olds) is warranted.
Acknowledgements We would like to thank the nursing staff of the
IWK Health Centre Childrens Day Surgery Unit, the surgeons and
office staff of the Division of Otolaryngology, Urology, General
Surgery, Gastroenterology, and Plastic Surgery, and the members of
the Department of Pediatric Anesthesia for their cooperation and
support. Funding for this study was provided by IWK Health Centre
Research Services. The first author was supported by a Fellowship
from the Canadian Institutes of Health Research (CIHR) at the time
the research was conducted. The third author is supported by a Killam
Research Professorship from the Dalhousie Faculty of Science and
was supported by an Investigator Award from the CIHR at the time the
research was conducted. The last author was supported by a Dalhousie
University Clinical Research Scholar Award at the time the research
was conducted. We thank Michelle Coffin, Alyson Currie, Jessica
Ferguson, Kathy MacDonald, and Matthew Murphy for their careful
work in administration, data collection, and data coding for the study.
We would also like to thank Dr. Leora Kuttner for providing high
quality prints of the CAPS faces to use in preparing the study
materials and for reviewing an earlier version of the present
manuscript.
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... Children experience anxiety when they are away from a familiar comfortable environment. 1 Hospital ward is one such location where children encounter apprehension as they are uncertain about the procedures they may be subjected to. Children have reported that they feel threatened while in contact with the health care system. 2 Further, there is substantial evidence to infer that children are more anxious than adults when they receive medical treatment and care. ...
... Anxiety is an internal state that cannot be fully measured by an observer. 1,4 It has been suggested that the most comprehensive assessment of anxiety should involve the use of a combination of behavioral, physiological and self-report measurement techniques. 5,6 Nevertheless, one of the best ways to assess anxiety is to ask the particular individual about this state. ...
... 5,6 Nevertheless, one of the best ways to assess anxiety is to ask the particular individual about this state. 1,4 There are numerous methods to measure general anxiety in children in the preoperative setting. These methods include self-report measurements including questionnaires for the assessment of anxiety. ...
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Introduction: Nurses are in an ideal position to provide special care for anxious children admitted in hospital wards. Thus, the objectives of the study were to identify the common nursing procedures done for children and to measure their level of anxiety. Methods: A cross-sectional descriptive study was conducted at a district hospital in Philippines. The respondents of the study were 235 children aged 3 – 9 years old admitted in the pediatric ward. The descriptive characteristics of the children were recorded. Venham Picture Test was used to assess the level of anxiety in children. The instrument was validated using the Good and Scates criteria and pre-tested on 30 pediatric respondents. The chi-square test and t-test were used to determine the significance of difference between the scores given by the children across different age groups and the P-value was set at 0.05. Results: The mean age of the respondents was 5.1 (3.5) years. Males obtained an "average" mean score of anxiety 4.0 (2.0) whilst females demonstrated a "low" mean score of anxiety 3.6 (2.3). There was a highly statistical difference between the mean anxiety scores amongst patients who had a prior experience and those who had none. Conclusion: Temperature measurement and pulse measurement were the most common procedures performed on children and demonstrated very low level of anxiety. Peripheral cannula insertion caused the maximum anxiety amongst all the procedures performed. Children aged 3 to 4 years old demonstrated the maximum anxiety when compared to children aged 5 to 9 years.
... Face scales are used by many hospitals to measure the pain or anxiety of children. These scales have been suitable for children as young as 4 years old [34,35]. Additionally, emotion cards have been used in the hospital context to investigate experiences of children [36]. ...
... However, the design of the survey tool had the following limitations: the different cognitive development stages of children from 4 to 17 years old, the hectic working pace at the hospital and the implementation of a digital survey on a tablet device. Children aged 4 to 17 were included because children as young as 4 are able to answer self-reported faces scales [34,35] and the age limit of the children's hospital was 17. ...
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Background: Because the healthcare sector is shifting to a customer-oriented approach, it is important to understand experiences of children as users of healthcare services. So far, studies that measure the influence of medical clowning on patient experiences are scarce. This study aims to measure experiences of children and their parents during day-surgery in hospital setting. Methods: A case-control study was conducted in a large Finnish children’s hospital. Seventy children aged 4–17 years coming for a minor operative procedure including pre-operative cannula insertion prior to surgery were included. Thirty-eight children were exposed to the medical clowning intervention and 32 children (the reference group) did not receive exposure to medical clowning. A novel digital survey tool was used to measure patient experiences before and after the insertion of a venous cannula needed for anaesthesia. The children were asked about their emotions, anxiety levels, the pain from the cannula insertion and the best and worst things about the hospital. The parents were asked about their emotions, expectations and the fluency of the procedure and the hospital day. Results: Before the procedure, 32% or 36% of the children in the intervention group and 44% or 28% of those in the reference group expressed positive or neutral emotions, respectively. After the procedure, 76% or 63% of children in the intervention group or reference group, respectively, expressed positive emotions. The intervention group rated the medical clowns as the best aspect of the hospital day. Both groups reported that the best aspects of the hospital day were related to the nurses and food and the worst were related to waiting and pain. Most commonly the parents felt uncertainty, anxiety or calmness before the procedure and relief afterwards. Their expectations towards the procedure related to its success and the certainty of the diagnosis. Conclusions: The results show a trend towards more positive emotions in children with exposure to medical clowning. The digital survey tool was suitable for gathering information about the experiences of children and their parents. Information on emotions and expectations of children and parents during a procedure is useful when improving the quality of healthcare services. Trial registration: Current Controlled Trials NCT04312217, date of registration 17.03.2020. Retrospectively registered. Keywords: Patient experience, children’s hospital, Children, Parents, Digital survey tool, Case-control study, Medical clowns
... Despite their strengths, there are some limitations to observer ratings. For example, although high inter-rater reliabilities on observer-rated measures of children's anxiety have long been reported in nonsurgical contexts (e.g., Glennon & Weisz, 1978), the reliance on overtly observed behaviors can result in inter-observer variability in assessment in the surgical setting (Wright et al., 2010(Wright et al., , 2013. Moreover, observer-rated measures may also have limited predictive potential in the surgical setting, since it measures preoperative anxiety at one specific time point. ...
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New technologies in mobile, wireless quantitative electroencephalography (EEG) allow for simple and non-invasive continuous monitoring of brain activity that may complement and enhance existing assessment tools that track preoperative anxiety in the surgical setting. Although individual differences in continuously monitored frontal brain electrical activity (EEG) are associated with anxiety in traditional laboratory settings, this relation has not been tested in the preoperative context. We measured continuous frontal and temporal EEG alpha power using a mobile, 4-sensor dry headband in 70 children (Mage = 10.36 years; 34 males) preparing for elective surgery across two separate visits: a preoperative visit approximately a week before surgery (visit 1), and during the day of surgery in the preoperative holding area (visit 2). We also measured preoperative anxiety at visit 2 using the self-reported Children’s Perioperative Multidimensional Anxiety Scale (CPMAS) and the observer-rated modified Yale Preoperative Anxiety Scale (mYPAS). Anterior EEG alpha power demonstrated very good internal consistency and good test–retest reliability. Furthermore, lower overall frontal EEG alpha power (i.e., greater frontal brain activity) at visit 1 correlated with higher self-reported state anxiety at visit 2. These findings provide preliminary evidence of the feasibility, reliability, and validity of using mobile, relatively non-invasive EEG measures to help understand and predict preoperative anxiety in children.
... Ces quatre options sont représentées schématiquement avec un système de quantité : la réponse 1 -« Jamais » est représentée sans aucune bille alors que la réponse 4 -« Beaucoup » est représentée avec de nombreuses billes. Également, une autre échelle basée sur des images de visages a montré une validité convergente acceptable avec le mYPAS lors d'une étude de validation menée auprès d'enfants âgés de 3 à 5 ans (Wright et al., 2010). Cette méthode alternative d'évaluation de l'anxiété pourrait fournir une donnée complémentaire au mYPAS (pour d'autres exemples d'échelles auto-rapportées, voir aussi Caldwell & Ray, 2017;Febvre et al., 2015). ...
Thesis
Les données de la littérature indiquent que la stratégie de distraction (e.g. jouets, distractions audiovisuelles) est efficace dans la régulation de l’anxiété préopératoire auprès des enfants. Il paraît cependant nécessaire de s’intéresser aux processus à l’œuvre dans l’efficacité de cette technique, notamment avec l’étude de l’état de flow (état d’intense concentration et d’absorption). La problématique de ce travail de recherche est d’évaluer si l’engagement de l’enfant sur l’activité distractrice peut influencer son effet bénéfique. Dans cette thèse l’étude 1, réalisée auprès de 50 adultes vise à développer et valider une grille d’observation du flow afin de pallier le manque d’outil de mesure du flow qui soit adapté au contexte péri-opératoire et aux enfants. Puis, trois études ont été menées dans un service d’anesthésie pédiatrique auprès de 100 enfants, afin d’étudier l’effet du flow, généré par une distraction technologique (jeu vidéo ou dessin animé), sur la régulation de l’anxiété préopératoire. Dans l’ensemble, les résultats obtenus mettent en évidence que les enfants en flow sur la distraction tirent davantage de bénéfices de cette intervention que les enfants faiblement en flow. Également, le flow montre un caractère dynamique au cours de l’attente. Par ailleurs, dans une démarche exploratoire, les répercussions postopératoires de l'anxiété ont été examinées ainsi que d’autres variables qui semblent moduler la relation entre flow et anxiété (rôle du parent accompagnateur et des soignants). Cela ouvre des perspectives prometteuses dans l’amélioration clinique de cette stratégie de régulation de l’anxiété.
... A sample size of minimum 102 participants was calculated using the mean (27.30) and standard deviation (6.24) from the method reported by Wright et al., 24 and was modeled to detect a mean difference of ≥4 in the mYPAS among the three groups (F-test, omnibus, one-way, alpha = 0.05%; power =80%) using the G*Power software. 25 To adjust and compensate for uncertainties in the power calculation and to account for drop-outs, the study was designed to include 150 participants. ...
Article
Background Anxiety in pediatric patients may challenge perioperative anesthesiology management and worsen postoperative outcomes. Sedative drugs aimed to reducing anxiety are available with different pharmacologic profiles, and there is no consensus on their effect or the best option for preschool children. Aim In this study, we aimed to compare the effect of three different premedications on anxiety before anesthesia induction in preschool children aged 2−6 years scheduled for elective surgery. The secondary outcomes comprised distress during peripheral catheter (PVC) insertion, compliance at anesthesia induction, and level of sedation. Methods In this double-blinded randomized clinical trial, we enrolled 90 participants aged 2−6 years, who were scheduled for elective ear-, nose-and-throat surgery. The participants were randomly assigned to three groups: those who were administered 0.5 mg/kg oral midazolam, 4 µg/kg oral clonidine, or 2 µg/kg intranasal dexmedetomidine. Anxiety, distress during PVC insertion, compliance with mask during preoxygenation, and sedation were measured using the modified Yale Preoperative Anxiety Scale, Behavioral Distress Scale, Induction Compliance Checklist, and Ramsay Sedation Scale, respectively. Results Six children who refused premedication were excluded, leaving 84 enrolled patients. At baseline, all groups had similar levels of preoperative anxiety and distress. During anesthesia preparation, anxiety was increased in the children who received clonidine and dexmedetomidine; however, it remained unaltered in the midazolam group. There were no differences in distress during PVC insertion or compliance at induction between the groups. The children in the clonidine and dexmedetomidine groups developed higher levels of sedation than those in the midazolam group. Conclusions In preschool children, midazolam resulted in a more effective anxiolysis and less sedation compared to clonidine and dexmedetomidine.
... 5,6 However, research into the perioperative management of children often excluded children with ASD in the past. 23,24 The aim of this study was to explore the experiences of children with ASD who underwent a day surgery procedure. We wanted to gain insight and understand the perspective of caregivers as they reflected on their journey through the health system at two major providers of health care in Melbourne, Australia. ...
Article
Background: Autism Spectrum Disorder is now diagnosed in more than 1% of children in Australia and USA. Children with autism spectrum disorder may have additional health care needs, require more specialized services for their health care, or experience more difficulties during hospital attendance. Customized care for these children may assist in decreasing potentially challenging behaviours during hospitalization. The purpose of this study was to explore the experiences of children with autism spectrum disorder and their caregivers during attendance for day procedures in two hospitals in Melbourne, Australia. Further, the perceptions of their health care providers were explored. Method: Twenty-nine participants, including 14 health care providers and 15 caregivers of children with autism spectrum disorder, were interviewed within 72 hours of their day procedure attendance at the Royal Children's Hospital and the Royal Dental Hospital in Melbourne, Australia. Interviews were recorded digitally, then transcribed and coded. Mixed quantitative and qualitative methods (content analysis) were used. Results: Hospital attendance was often stressful. Participants identified a number of facilitating factors including good communication, clear explanations, and friendly attitudes of staff. Flexibility and individualized care of patients (such as avoiding unnecessary blood pressure measurements, and not changing into hospital gowns) were valued. Supportive aids (such as computers or special interest objects), use of social stories, and giving premedication were all considered helpful. Perceived barriers to care included prolonged waiting times for operation date as well as waiting on the day of operation, lack of private space, lack of noninvasive equipment such as cutaneous infrared thermometers, poor communication, and inadequate training of staff about autism spectrum disorder. Conclusion: Providing optimal care for children with autism spectrum disorder requires a multifaceted approach that may require changes to hospital work flow, staff training, better use of aids (such as tablet computers and social stories), and premedication. Good communication and flexibility are key areas of importance.
... Yale Ameliyat Öncesi Anksiyete Skalası (Kain ve ark., 1997) çocuğun ameliyat öncesi anksiyetesini değerlendirmektedir. Çocuk Anksiyete ve Ağrı Ölçeği-Anksiyete Alt Ölçeği de yine benzer olarak günübirlik cerrahi işlemlerinde çocukların anksiyetesini değerlendirmektedir (Wright, Eisner, Stewart, Finley, 2010). Çocuk Distresi Gözlemsel Ölçeği-Revize Formu (Elliott, Jay, Woody, 1987) ve Çocuk-Yetişkin Medikal İşlem Etkileşim Skalası-Revize Formu (Blount ve ark., 1997) çocuğun stresini ölçen diğer ölçeklerdir. ...
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Giriş: Hastane ortamında çocuklar birçok korku ve anksiyete yaratan durumla karşılaşmaktadırlar. Ancak ülkemizde hastane ortamında küçük yaş grubundaki çocukların korku ve anksiyetelerini değerlendirebilecek ölçekler bulunmamaktadır. Amaç: Metodolojik olarak planlanan çalışmada Çocuk Anksiyete Skalası-Durumluluk (ÇAS-D) ve Çocuk Korku Ölçeğinin (ÇKÖ) Türk diline kazandırılması amaçlanmıştır Yöntem: Örneklem 4-10 yaş arası flebotomi uygulanan 135 çocuğu içermiştir. Veriler, Ocak-Nisan 2017 tarihleri arasında, Abstract Gaining of Children's State Anxiety and Children's Fear Scale to Turkish Language Background: In the hospital environment, children are faced with many anxiety and fear situations. However, there are no scales that can assess the anxiety and fear of children in the small age group during the invasive procedures in our country. Objectives: This methodological study was performed to gain of Children's State Anxiety (CSA) and Children's Fear Scale (CFS) to Turkish Language. Methods: The study sample was composed of 135 children undergoing phlebotomy aged 4-10 years. The data were obtained by using the socio-demographic data collection form, CSA and CFS. For both scales, the translation back translation method was used and the content validity index was evaluated. Test-retest method and correlation analysis were used, and regression analysis was used to determine the factors that explain CSA and CFS scores. Results: The content validity index were 1.00 and 0.89, respectively for CSA and CFS. There was a high level of positive correlation between the CSA average score and the CFS average scores assessed by the child, the parent and the researcher. It was found that there was a significant negative correlation between the children's anxiety scores and their ages; and that there was a significant negative correlation between the children's fear scores and their ages and a positive relationship with the presence of chronic illness. Conclusion: According to our results, it has been shown that the CSA and CFS Turkish version is a valid/reliable for Turkish children. Age and chronic illness are two important variables on fear and anxiety, and studies on reducing fear and anxiety can be planned in young children with chronic illness.
... The measure is a five-item visual analog scale that quantifies perioperative anxiety numerically from 0 to 500. Children as young as 3 years are able to self-report on anxiety (Wright, Eisner, Stewart, & Finley, 2010), and as long as they have the ability to comprehend space, numbers, and distance, they are able to correctly self-report on their anxiety levels using VAS scales (Foster & Park, 2012). By age 7, concrete operations emerge: children develop an understanding of their mental operations, and so the majority of children older than 7 are capable of reporting their feelings accurately. ...
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Up to 5 million children are affected by perioperative anxiety in North America each year. High perioperative anxiety is predictive of numerous adverse emotional and behavioral outcomes in youth. We developed the Children’s Perioperative Multidimensional Anxiety Scale (CPMAS) to address the need for a simple, age-appropriate self-report measure of pediatric perioperative anxiety in busy hospital settings. The CPMAS is a visual analog scale composed of 5 items, each of which is scored from 0–100. The objective of this study was to assess the psychometric properties of the CPMAS in children undergoing surgery. Eighty children aged 7 to 13 years who were undergoing elective surgery at a university-affiliated children’s hospital were recruited. Children self-completed the CPMAS and the Screen for Childhood Anxiety Related Disorders (SCARED-C) at 3 time points: at preoperative assessment (T1), on the day of the operation (T2), and 1 month postoperatively (T3). Internal consistency, test–retest reliability, and the convergent validity of the CPMAS were assessed across all 3 visits. The CPMAS demonstrated good internal consistency (Cronbach’s alpha ≥ .80) and stability (ICC = 0.71) across all 3 visits. CPMAS scores were moderately correlated with total SCARED-C scores (r values = .35 to .54, p values
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Preoperative emotional distress in children should be addressed properly for better anesthetic experience. The present study was a Prospective randomized double-blind study to evaluate comparative efficacy of three different doses of intranasal dexmedetomidine for premedication in children. Sixty children were then randomly allocated to one of the three groups of 20 each by a computer generated table. The drug was administered 45 minutes prior to induction of anesthesia intra-nasally. Following intra-nasal drug administration, anxiety was assessed at 0 minutes -baseline, 30 minutes, 45 minutes and at parental separation in the preoperative area just before shifting in operation theater using the mYPAS (modified Yale Preoperative Anxiety Scale). At induction, induction compliance was assessed using the induction compliance checklist and heamodynamic response to definitive airway was assessed. It was observed that intranasal dexmedetomidine in lower doses of 0.5 and 1µg/kg was effective in reducing anxiety from baseline values but was not sufficient for providing anxiolysis at the most stressful time - at parental separation and shifting to OR (Operating room). The dosage of 1.5µg/kg was found to be the most effective dose for allaying preoperative anxiety without any adverse effect. However, this dose was insufficient for optimizing induction as it is mainly anxiolytic and higher doses having additional sedative action may be required to make the child more compliant for induction of anesthesia. Based on our findings, we recommend that intranasal dexmedetomidine in the dose of 1.5µg/kg can be used for allaying preoperative anxiety, without any adverse events. • Question: To evaluate and compare the efficacy of three different doses of intranasal dexmedetomidine for premedication in children for preoperative anxiety using the mYPAS scale. • Findings: Dose of 1.5µg/kg can be used for allaying preoperative anxiety, without any adverse events. • Meaning: Optimum dose of intranasal dexmeditomedine which is efficient to allay preoperative anxiety in children.
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El miedo y la ansiedad han sido reconocidos como los principales motivos que dificultan la atención del niño en odontología, por lo cual se ha propuesto el uso de instrumentos de evaluación, para conocer los valores de éstos en pacientes odontopediátricos. Son pocas las investigaciones realizadas sobre este tema en Latinoamérica, a pesar de su relevancia. Objetivo: Evaluar los niveles de ansiedad y miedo dental infantil según la edad en niños que acudieron al servicio de Odontopediatría de la Facultad de Odontología Universidad de Carabobo. Material y Métodos: El diseño utilizado fue no experimental y transeccional de tipo descriptivo y correlacional. Se consideró una muestra de 120 escolares, a quienes se les aplicó la Escala de Ansiedad de Corah, Escala de evaluación de miedos dentales y Test de dibujos de Venham. Resultados: El 89,17% de los niños, presentaron ansiedad según el Test de dibujos de Venham, mientras la Escala de Ansiedad de Corah evidenció ansiedad en un 80,8%, arrojando a los 6 años de edad un nivel de ansiedad alto con un 20%, destacando en la Escala de evaluación de miedos dentales un porcentaje de 70,9%, donde se tuvo que a los 6, 7 y 8 años destacó un nivel de miedo dental alto entre el 16-22% respectivamente. Conclusiones: Los niveles de miedo y ansiedad dental infantil disminuyeron conforme avanza la edad, expresándose a los 6 años en mayor porcentaje, en esta investigación las ilustraciones hechas por los pacientes describieron niveles de ansiedad moderados y altos en un 76%.
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Compared responses on a checklist of distress behaviors to ratings of medical-procedure-related pain and anxiety by 29 male and 21 female 6–17 yr old cancer patients and 1 adult observer. Results show that children showed greater behavioral distress than adolescents only during the actual medical procedure; however, additional behaviors were observed that suggested that the checklist was age-biased and that the 2 age groups experienced an equal amount of stress. This assumption was supported by a measure of intensity, observer reports, and patient self-reports, which showed no differences between the 2 age groups. None of the measures showed any significant differences for sex or ethnic origin. Data show that children had less physical control and more emotional outbursts than adolescents during a stressful procedure. It is concluded that clinical research on pain and anxiety should incorporate both self-report and observer data. (18 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Reviews self-report instruments in current pediatric pain research noting their limitations and advantages. Early instruments are examined and face scales in current use discussed. Specifically, the work of J. E. Beyer (1984); L. Kuttner and T. LePage (1983); and P. A. McGrath et al (1985) was highlighted as indicative of the trend toward more reliable and valid instruments that also have psychometric sophistication. The trend toward face scales with more complex stimuli and possessing greater empathic value is noted. Suggestions are offered toward resolving research problems across developmental ages by the creation of different instruments for different ages. Areas for future research are discussed and the role of face scales in the further development of pain research in children is underlined. (French abstract) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The 1956 adaptation for children of Taylor's Manifest Anxiety Scale, the Children's Manifest Anxiety Scale, was revised to meet current psychometric standards. A 73-item revision draft was administered to 329 school children from grades 1 to 12. Based on item-analysis criteria for rbis greater than or equal to .4 and .30 less than or equal to p less than or equal to .70, 28 anxiety items were retained along with 9 of the original 11 Lie scale items. A cross-validation sample of 167 children from grades 2, 5, 9, 10, and 11 produced a KR20 reliability estimate of .85. Anxiety scores did not differ across grade or race. Females scored significantly higher than males. For the Lie scale, significant differences appeared by grade and race. No sex differences were obtained on the Lie scale. The resulting scale appears useful for children in grades 1 to 12 and may aid in future studies of anxiety as well as assisting the clinician in the understanding of individual children.
Article
Objective: To determine predictors and behavioral outcomes of preoperative anxiety in children undergoing surgery.Design: A prospective, longitudinal study.Setting: A university children's hospital.Participants: One hundred sixty-three children, 2 to 10 years of age (and their parents), who underwent general anesthesia and elective surgery.Main Outcome Measures: In the preoperative holding area, anxiety level of the child and parents was determined using self-reported and independent observational measures. At separation to the operating room, the anxiety level of the child and parents was rated again. Postoperative behavioral responses were evaluated 3 times (at 2 weeks, 6 months, and 1 year).Results: A multiple regression model (R2=0.58, F=6.4, P=.007) revealed that older children and children of anxious parents, who received low Emotionality, Activity, Sociability, and Impulsivity (EASI) ratings for activity, and with a history of poor-quality medical encounters demonstrated higher levels of anxiety in the preoperative holding area. A similar model (R2=0.42, F=8.6, P=.001) revealed that children who received low EASI ratings for activity, with a previous hospitalization, who were not enrolled in day care, and who did not undergo premedication were more anxious at separation to the operating room. Overall, 54% of children exhibited some negative behavioral responses at the 2-week follow-up. Twenty percent of the children continued to demonstrate negative behavior changes at 6-month follow-up, and, in 7.3% of the children, these behaviors persisted at 1-year follow-up. Nightmares, separation anxiety, eating problems, and increased fear of physicians were the most common problems at 2-week follow-up. Multivariate analysis demonstrated that child's age, number of siblings, and immediate preoperative anxiety of the child and mother predicted later behavioral problems.Conclusions: Variables such as situational anxiety of the mother, temperament of the child, age of the child, and quality of previous medical encounters predict a child's preoperative anxiety. Although immediate negative behavioral responses develop in a relatively large number of young children following surgery, the magnitude of these changes is limited, and long-term maladaptive behavioral responses develop in only a small minority.Arch Pediatr Adolesc Med. 1996;150:1238-1245
Article
Unlabelled: We determined whether children who are extremely anxious during the induction of anesthesia are more at risk of developing postoperative negative behavioral changes compared with children who appear calm during the induction process. Children (n = 91) aged 1-7 yr scheduled for general anesthesia and elective outpatient surgery were recruited. Using validated measures of preoperative anxiety and postoperative behaviors, children were evaluated during the induction of general anesthesia and on Postoperative Days 1, 2, 3, 7, and 14. Using a multivariate logistic regression model, in which the dependent variable was the presence or absence of postoperative negative behavioral changes and the independent variables included several potential predictors, we demonstrated that anxiety of the child, time after surgery, and type of surgical procedure were predictors for postoperative maladaptive behavior. The frequency of negative postoperative behavioral changes decreased with time after surgery, and the frequency of negative postoperative behavioral changes increased when the child exhibited increased anxiety during the induction of anesthesia. Finally, we found a significant correlation (r) of 0.42 (P = 0.004) between the anxiety of the child during induction and the excitement score on arrival to the postanesthesia care unit. We conclude that children who are anxious during the induction of anesthesia have an increased likelihood of developing postoperative negative behavioral changes. We recommend that anesthesiologists advise parents of children who are anxious during the induction of anesthesia of the increased likelihood that their children will develop postoperative negative behavioral changes such as nightmares, separation anxiety, and aggression toward authority. Implications: Anesthesiologists who care for children who are anxious during the induction of anesthesia should inform parents that these children have an increased likelihood of developing postoperative negative behavioral changes.